UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Tiffany Tran

MSI & MSII PATIENT ASSESSMENT TOOL

1 PATIENT INFORMATION

Assignment Date: 08/30/2016

Agency: TGH SBN

Patient Initials: DP

Age: 55 year old

Admission Date: 08/26/2016

Gender: Male

Marital Status: Married

Primary Medical Diagnosis: Idiopathic pulmonary

fibrosis (ICD-10: J84.112); Respiratory distress
(J80)

Primary Language: English

Level of Education: Bachelors in psychology
Occupation (if retired, what from?): Certified surgical technician

Other Medical Diagnoses: (new on this admission)

See above (Primary Medical Diagnosis)

Number/ages children/siblings: 3 childrenages 27, 30, 31

Served/Veteran: 13 years as army medic
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives with his wife at home. He was
ambulatory prior to this visit. He denies having stairs or unsafe
obstacles to navigate at home. Neither the patient nor his wife is
diagnosed with Alzheimers. The patient and his wife have a
comprehensive list of his medications and medical/surgical history
and are abreast of his treatment plan. Patients wife is his advocate.

Code Status: Full code

Advanced Directives: No
If no, do they want to fill them out?: Patient
interested in advanced directive. RN notified and
pastoral care consulted to assist patient with
advanced directive.
Surgery Date: N/A Procedure: N/A

Culture/ Ethnicity /Nationality: African American per patient

Religion: Christian

Type of Insurance: UMR

1 CHIEF COMPLAINT: Patient states, Id been having shortness of breath since around May, but it got
really bad like Wednesday last week. I started getting this cough and, once I get started, I desat really bad. We
called the doctor, but it was taking forever to do all the tests we needed and it got so bad that we finally just
came to the ER on Friday.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay): Patient was admitted to TGH on 08/26/2016. He presented with shortness of breath and dry cough. Patient stated the
onset of his symptoms was this past May (2016), but that the cough developed and worsened within the past week. Patient
reported that whenever he would cough, he would desat and be unable to catch his breath. His symptoms were/are located
in his chest/lungs (as he is dyspneic), in his throat (from his dry cough) and in his lower back (exacerbating an old injury
that he suffered during his service in the army). Patient states that the duration of his coughing spells is about 20-30
minutes and this happens several times a day (3-6). Patient also states his coughing spells are accompanied by lower back
pain that lasts for about 15-20 minutes. In regards to the character of his cough, it is dry or nonproductive and causes
dyspnea. He reports his lower back pain is throbbing and radiates when he begins coughing. Patient states his symptoms
are aggravated by perfumes, coughing, sneezing, and any activity that requires physical exertion. Patient reports his
symptoms are relieved by focusing on his breathing, the benzonatate that the hospital has given him, and the lidocaine
patch that he receives for his lower back pain. Patient advised that, on Wednesday 08/24/2016, when he called his doctors
office, he was given prescriptions for benzonatate (TESSALON), budesonide-formoterol (SYMBICORT), and an
ipratropium-albuterol (DUO-NEB) nebulizer as treatment. He advised that he tried to treat at home by focusing on his

University of South Florida College of Nursing Revision September 2014

breathing and taking these medications, but these treatments did not suffice for his shortness of breath. Patient reports the
severity of his shortness of breath is 0-1 when he is not coughing or sneezing, but is a full 10 when he is. Patient has
continued receiving these medications during his stay at TGH as well as 5 liters of supplemental oxygen via nasal
cannula. Patient received an EKG upon arrival to rule out myocardial infarction as well as a CT Chest without contrast
and CXR. His EKG was benign and his CT showed the following: 1. Diffuse reticulation, traction bronchiectasis and
bronchiolectasis, and groundglass opacities in the lower lobe, peripheral, and basilar predominance. Differential diagnosis
includes fibrotic nonspecific interstitial pneumonia, atypical usual interstitial pneumonia, or desquamative interstitial
pneumonia; 2) Mediastinal lymphadenopathy, nonspecific and likely reactive; 3) Slightly enlarged pulmonary trunk,
which can be seen in the setting of pulmonary hypertension; and 4) Atherosclerosis and coronary artery disease. The
patient is now working with the transplant team and is being evaluated as a potential lung transplant candidate. Today, he
is scheduled for a home-O2 evaluation, pulmonary function test, six-minute walk test, and CT angiogram with IV contrast.
On Thursday, 09/01/2016, he will stand before the transplant committee to hear their decision on whether or not he is a
viable candidate for lung transplant.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
Unknown
Year 1995
Unknown

Operation or Illness
Left osteotomy (high tibia)
Right patellar tendon repair
Hamstring repair

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Patient denies further medical/surgical history. Until May, patient denies having any problems with
dyspnea.

Father
Mother

Unk

Brother

Unk

Sister

Unk

relationship
relationship
relationship

Comments: Patient denies knowing ages of onset.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?

YES

University of South Florida College of Nursing Revision September 2014

NO

U
U
U
U
U

Have you had any other vaccines given for international travel or
occupational purposes?: Yellow fever (during military service)
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Medications
Other (food, tape,
latex, dye, etc.)

Type of Reaction (describe explicitly)

Patient denies medication allergies.

Perfumes
Cleaning agents

Patients sensitivity to perfumes and chemical agents causes coughing,

sneezing, and dyspnea. Patient reports this sensitivity is newly onset
along with his idiopathic pulmonary fibrosis

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).
_____The patient was diagnosed with idiopathic pulmonary fibrosis (IPF) during this hospitalization. IPF is characterized
by usual interstitial pneumonia (UIP), which is virtually unexplained scarring of the lung tissue. For this reason, it is also
sometimes known as interstitial lung disease (ILD). This unexplained scarring of the lung tissue leads to
restricted/diminished lung capacity and expansion, which results in exertional breathlessness and decreased activity
tolerance. This disease process involves progressively worsening interstitial pulmonary fibrosis (lung tissue scarring),
resulting in progressively deteriorating alveolar gas exchange. The majority of patients suffering from IPF do not survive
more than 5 years after diagnosis.
_____IPF is a difficult disease process to diagnose because it is diagnosed by reasonably excluding other possible
diagnoses. In this patients case, despite the fact that he was previously a smoker, he was formally diagnosed with
idiopathic pulmonary fibrosis after using a chest CT angiogram (without contrast), chest X-rays, EKGs, and a full patient
history to exclude other possible causes of his pulmonary fibrosis. Furthermore, this patients provider would be following
up these tests with an array of tests including pulmonary function tests, 6-minute walk tests, another chest CT angiogram
(with contrast), and the like.
_____Although diagnosis is difficult, more difficult yet is the treatment of IPF. Treatments of IPF are rather limited and
most pharmacologic treatments have yet to be conducted in comparison with the effectiveness of placebos. Even still,
pharmacotherapy could include the use of corticosteroids and/or immunosuppressants to decrease the inflammation of the
lung. Additionally, treatments can be supportive; such as supplemental oxygen can be utilized to treat the symptoms of
IPF such as exertional breathlessness or ineffective/impaired gas exchange. Patients can also be referred to physical
therapy to receive recommendations on how to manage their decreased activity tolerance or to a dietitian in order to
address their increased nutritional needs to support their impaired mechanical ventilation. Even still, thus far, the only
intervention that has been proven to benefit patients with IPF is receiving a lung transplant. Lung transplantation does
come with its own set of complications, including necessary lifelong immunosuppressant medications, risk for host versus
graft or graft versus host disease, as well as the potential for a related complication called bronchiolitis obliterans
syndrome (BOS). BOS is characterized by the continued fibrosis of the terminal bronchioles, leading to the declined
function of the transplanted lungs. At this point, treatment of BOS is lacking even more than that of IPF.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name:benzonatate(TESSALON)
Concentration:100mg
DosageAmount:100mg
Route:PO(capsule)
Frequency:3timesdailyPRNcough
Pharmaceuticalclass:Antitussives
HomeHospitalorBoth
Indication:Cough
Adverse/Sideeffects:Sedation,headache,dizziness,pruritus,nausea,constipation,confusion,hypersensitivityreaction

University of South Florida College of Nursing Revision September 2014

Nursingconsiderations/PatientTeaching:Teachpatienttoriseslowlyandwithassistanceanddrinkfluids.Monitorforsignsof
anaphylaxis.
Name:budesonideformoterol(SYMBICORT) Concentration:1604.5mcg/actuation

DosageAmount:2puffs

Route:Inhalation
Frequency:2timesdaily
Pharmaceuticalclass:Corticosteroids/Longactingbeta2
HomeHospitalorBoth
agonists(LABAs)
Indication:Bronchodilationandinflammationfordyspnea
Adverse/Sideeffects:Bronchospasm(paradoxical),asthmaexacerbation,asthmarelateddeath,pneumonia,hypersensitivityreaction,
hypertension,hypotension,angina,cardiacarrest,glaucoma(longtermuse),cataracts(longtermuse),adrenalsuppression
Nursingconsiderations/PatientTeaching:Patientshouldbeassessedforhistoryofasthma.Patients,especiallythosewithasthma,
shouldbemonitoredforrespiratorydepressionorcompromise.Patientsshouldalsobeadvisedtohaveannualeyeexams.
Name:docusatesodium(COLACE)

Concentration:100mg

DosageAmount:100mg

Route:PO(capsule)
Frequency:2timesdaily
Pharmaceuticalclass:Emollientlaxatives
HomeHospitalorBoth
Indication:Prophylaxisforconstipationfromdiminishedmobility
Adverse/Sideeffects:Diarrhea,abdominalcramps,throatirritation,rash,electrolytedisorders
Nursingconsiderations/PatientTeaching:Encouragepatienttotakewithfluids,especiallyifbeginningtoexperiencediarrhea
(replacefluids).Holdifpatientisexperiencingdiarrhea.Checkpatientslabresultsforelectrolyteimbalances.
Name:famotidine(PEPCID)

Concentration:40mg

DosageAmount:40mg

Route:PO(tablet)
Frequency:daily
Pharmaceuticalclass:Histamine2(H2)blockers
HomeHospitalorBoth
Indication:Prophylaxisforupsetstomachandstomachulcersfrommedications
Adverse/Sideeffects:Headache,dizziness,constipation,diarrhea,tastechanges,vitaminB12deficiency(longtermuse),anaphylaxis,
angioedema,toxicepidermalnecrolysis,leukopenia,thrombocytopenia,pancytopenia,seizures,AVblock,arrhythmias,CNStoxicity,
hepatitis,QTprolongation(renalimpairedpatients)
Nursingconsiderations/PatientTeaching:Teachpatienttoriseslowlyandwithassistance.Possiblymonitorheartrhythm
(telemetry),especiallyforrenalcompromisedpatients.Additionally,checkcreatinine/BUNforrenalcompromisedpatients(Doesnot
pertaininthiscase).
Name:heparin(porcine)

Concentration:5000units/mL

DosageAmount:5000units

Route:Subcutaneousinjection
Frequency:Q8h,threetimesdaily
Pharmaceuticalclass:Anticoagulants
HomeHospitalorBoth
Indication:ProphylaxisforVTEwhileinthehospitalandmobilityisdiminished
Adverse/Sideeffects:Bleeding,thrombocytopenia,prolongedclottingtime,localinjectionsitereaction,hypersensitivityreaction,
urticaria,fever,rigors,ALT/ASTelevated,osteoporosis(longtermuse),hemorrhage,heparininducedthrombocytopenia,anaphylaxis
Nursingconsiderations/PatientTeaching:Monitorpatientforseverebleedingorbruisingandteachpatienttodothelike.Monitor
patientsaPTTatbaselineandthroughouttherapy,especiallypriortogivingnextdose.Rotateinjectionsitestoprevent
lipohypertrophy.
Name:hydrocodonechlorpheniramine
Concentration:108mg/5mLsuspension DosageAmount:5mL
(TUSSIONEX)
Route:PO(suspension)
Frequency:Q12hPRNcough
Pharmaceuticalclass:Antitussives/Antihistamines
HomeHospitalorBoth
Indication:Cough
Adverse/Sideeffects:Drowsiness,confusion,impairedcoordination,anxiety,moodchanges,dizziness,nausea,vomiting,
constipation,visionchanges,headache,rash,respiratorydepression,hypotension,paralyticileus,intestinalobstruction,withdrawal
symptomsifabruptdischarge(withprolongeduse)
Nursingconsiderations/PatientTeaching:Teachpatienttoriseslowlyandwithassistance.Encouragepatienttodrinkfluidsand

University of South Florida College of Nursing Revision September 2014

reportconstipation.Monitorpatientforrespiratorydepression.Teachpatienttoreportvisionchanges,dizziness,orheadache.
Name:ipratropiumalbuterol(DUONEB)

Concentration:0.53mg(2.5mgbase)/ DosageAmount:3mL
3mLnebulizersolution
Route:Aerosol/Nebulizer
Frequency:Q4hRespiratory
Pharmaceuticalclass:Anticholinergics/Shortactingbeta2
HomeHospitalorBoth
agonists(SABAs)
Indication:Bronchodilationandsmoothmusclerelaxationfordyspnea
Adverse/Sideeffects:Pharyngitis,chestpain,bronchospasm(paradoxical),anaphylaxis,hypersensitivityreaction,hypertension,
hypotension,angina,cardiacarrest,arrhythmia,hypokalemia,hyperglycemia
Nursingconsiderations/PatientTeaching:Therespiratorytherapistwilladministerthenebulizertothepatient.Thepatientshould
receivethetreatmentinasemiFowlerstoFowlerspositiontopromotebetterairflow.
Name:lidocaine(LIDODERM)

Concentration:5%

DosageAmount:1patch

Route:Transdermal
Frequency:Q24h
Pharmaceuticalclass:Localanalgesics
HomeHospitalorBoth
Indication:Lowerbackpain(whichwasexacerbatedbythecoughingepisodes)
Adverse/Sideeffects:Applicationsitereaction,localerythema,localedema,localburningordiscomfort,abnormalsensations,
urticaria,anaphylactoidreaction,CNSexcitation,CNSdepression,cardiacarrest,seizures,coma
Nursingconsiderations/PatientTeaching:Cleanoldsitethoroughlyandrotatesiteofapplication.Teachpatientnottoapplyheatto
thesiteofthepatch.Monitorpatientforsignsofallergicreaction.

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?: MCLS (heart healthy)
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:

Breakfast: 1 cup instant oatmeal (with milk and

margarine), 2 medium (5 across) plain pancakes, 4
tablespoons Mrs. Butterworth (Log Cabin butter blends), 1
cup orange juice
Lunch: lb McDonalds cheeseburger with tomato and
ketchup on sesame seed bun, 1 medium McDonalds
French fries, 1 medium (22 fl oz) soft drink
Dinner: 1 cup mashed potatoes with milk and butter, 1
medium slice of meat loaf made with beef, 1 cup dry mix
gravy, 1 cup whole milk (calcium fortified)
Snacks: 1 ounce (20 halves) of pecans, 1 wedge (approx.
of melon) raw honeydew melon
Liquids (include alcohol): 1 cup fruit smoothie made with
whole milk

As evidenced by the graph above, the patient meets and

exceeds his daily needs in most of the food groupsgrains
(116%), fruits (147%), dairy (120%) and protein foods
(128%). The only food group he was lacking in was
vegetables (88%). Although his diet was balanced in terms
of food group targets, the patients choices were not always
the healthiest. His total calories eaten exceeded his total
limit (3259/2000). His choices included mostly refined
grains over whole grains, almost 3 times as much added
sugars, almost 2 times as much saturated fat, and more than
2 times as much sodium than he was allotted. In order to
decrease his carbohydrates, saturated fat and sodium, the
patient could begin by reducing his fast food intake. He
could also minimize the amount of juice he is drinking, as it
adds sugar to his diet, but lacks the fiber of whole fruits.
Finally, the patient could substitute some of his refined
grain choices for whole grains as well as substitute some of
his sugar or milk products with sugar-free or fat-free/lowfat options. This would greatly reduce the hidden calories
in his diet intake, but would still allow him the variety and
balance that he has already achieved at home.
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)

University of South Florida College of Nursing Revision September 2014

Who helps you when you are ill?: Patient states his wife (who is at bedside) lives with him and helps him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?: Patient states that he is never
usually stressed or anxious and has only become anxious recently because he knows he needs a lung transplant in order to
live and be able to work so he feels he is in a fight for [his] life. Patient advises, usually, he does not stress and, if he
gets upset, he is direct and can be confrontational. He states that he prefers to deal with the issue directly and move on
from the potential stressor. Patient advised that, now that he has this anxiety, his prayer and relationship with God has
been helping him.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): Patient
denies feelings of depression or difficulties with relationships, friends or his social life. Patient states that he is anxious
and overwhelmed by his new diagnosis, but that he feels this is normal for anyone who is receiving news of this
magnitude.

+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:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your patients age group: The patient is 55 years old and, thus, is in the middle adulthood developmental stage of his life. In this
stage of his life, a person will be in the psychosocial crisis of generativity versus self-absorption/stagnation. If a person is achieving
generativity, he will be able to not only care for himself, but to care and give to others as well. If a person is stalled in selfabsorption/stagnation, however, he will be unable to be generous emotionally with others and unable to care for others, meaning he
will be unable to grow as a person.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient demonstrates that he is succeeding in resolving the psychosocial crisis of his developmental stage by achieving
generativity. He exhibits this through his behavior with his wife as well as his numerous other visitors. He and his wife communicate
openly and he demonstrates caring for her as well as being able to receive love and care from her. The patient listens to his wife and
shows her that he needs her as well as cares for her and wants her to be an integral part of his healthcare as well as his life.
Additionally, the patient interacts openly and pleasantly with his steady volume of visitors, who all speak highly of him. Furthermore,
the patient is kind to his caretakers, his nursing student included. He offers compliments, humorous jokes, and words of wisdom to
everyone who enters his room. Finally, despite his diagnosis and anxiety, he is talkative and in good spirits, as he tries to continue to
relate to his company and his caretakers.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: As stated
above, despite his diagnosis, hospitalization, and anticipation of the transplant committees decision, the patient continues to
demonstrate generativity. He continues to be kind to others and giving of himself, which in turn, seems to help his spirits.

University of South Florida College of Nursing Revision September 2014

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: Patient states that the cause of his illness is unknown and he does not
feel that anything he has done has caused his illness.
What does your illness mean to you?: Patient states that he feels this is a life or death situation and he is worried that he
might have to stop working. He states that he feels he is in a fight for his life now and that if he goes before the board on
Thursday and they deny him the lungs he needs, he will be dead unless he receives a miracle from God.

+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?:_____No_________________________________________
Have you or your partner received the Gardasil (HPV) vaccination?: _____No_______________________________
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?: ___None (monogamous relationship with wife who is post-menopausal)__________________
How long have you been with your current partner?:_____15 years_________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity?: ___Patient declined
answering this question.______________________________________________________________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy?:
Patient denies having concerns about sexual health or how to prevent sexually transmitted disease or
unintended pregnancy._______________________________________________________________________________

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?: Patient states that spirituality, religion and family receive a 10 out
of 10 in terms of importance in his life.____________________________________________________________________________
____________________________________________________________________________________________________________
Do your religious beliefs influence your current condition?: Patient states that his religious beliefs positively influence his current
condition. He states that his religious beliefs give him fortitude and his prayers give him comfort.______________________________
____________________________________________________________________________________________________________

+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?: Cigarettes
How much?(specify daily amount):
1 pack per 2 days (10 cigarettes/day)

Yes
No____________
For how many years?: 20
(age: 18

thru: 38

If applicable, when did the

patient quit?: Age 38 (1999)

Pack Years: 10 pack years

Does anyone in the patients household smoke tobacco? If
so, what, and how much?: No

Has the patient ever tried to quit?: Yes

If yes, what did they use to try to quit?: No aids were
used per patient

2. Does the patient drink alcohol or has he/she ever drank alcohol?:
Yes
What?: Beer
How much?: 2 glasses
Volume: 8 ounces
Frequency: Every weekend during
his military service (when younger),
but less than once every 3 months
now
If applicable, when did the patient quit?:
Patient stated that he reduced his drinking
when he was in his late twenties.

No
For how many years?: 9
(age: 18

thru: 27

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?: Patient states he smoked marijuana in the military service, but denies ever using cocaine, heroin or any
other street drugs.
How much?: Patient states he
For how many years?: 9
cannot remember.
(age: 18

Is the patient currently using these

drugs? Yes No

thru: 27

If not, when did he/she quit?:

Patient states he quit in his late
twenties.

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?: Patient states
he is a surgical technician for a living and that he may be exposed to any number of chemicals or unknown hazards and
risks, including radiation. Patient denies awareness of any specific exposures.
5. For Veterans: Have you had any kind of service related exposure?: Patient states he served as an army medic for 13
years and that he was exposed to nuclear and biochemical training. Additionally, patient states he lived in Japan for 7 years
and could have been exposed to lingering radiation. Patient denies, however, awareness of any specific exposures.

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 0
Bathing routine: Daily shower at home
(Daily CHG bath at hospital)
Other: Denies use of sunscreen or
problems with integumentary system

HEENT
Difficulty seeing

Wears glasses

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction

Appendicitis

Enlarged lymph nodes

Abdominal Abscess
Last colonoscopy?
Other: Denies GI symptoms

Genitourinary

Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: Unknown
Other: Patient denies problems with
hematologic or oncologic systems.
Diabetes

1x/year

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

Cardiovascular
Hypertension
Denies medication

Chest pain / Angina

Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus

Hematologic/Oncologic

Metabolic/Endocrine
Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other: Patient denies problems with
metabolic/endocrine systems

Pulmonary

Hyperlipidemia

Other: Patient denies problems with

immunologic system.
Anemia

nocturia Patient states is his

baseline
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 3-6x/day
Bladder or kidney infections

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
2x/day
Routine dentist visits
Vision screening
1x/year
Other:

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
1x/year
Date of last prostate exam? Unknown
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other: Patient denies problems with CNS

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries/Fx
Weakness

Old lower back injury

With new Dx & cough

Childhood Diseases
Measles

University of South Florida College of Nursing Revision September 2014

With new Dx

Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 08/26/16
Other: Patients rhythm is sinus rhythm
and sometimes sinus tachycardia.

Pain
With coughing & sneezing
Gout
Osteomyelitis
Arthritis
Left knee arthritis
Other:

Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?: 20 pounds
Time frame?: About 1 month (the month of August)
Intentional?: Unintentional
How do you view your overall health?: Patient is worried about his weight loss. He has lost a lot of weight since his dyspnea onset
and he is worried that he will be unable to regain his strength.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?: Patient
denies any further problems that he did not mention and for which he believes he needs medical attention.
Any other questions or comments that your patient would like you to know?: Patient denies having any other
questions or comments.

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General Survey:
Temperature: 97.3F oral

Height: 511
Pulse: 91
Respirations: 22
SpO2: 97%

Weight: 69.9 kg
BMI: 21.5
Blood Pressure: 102/80 (88) taken on
left arm
Is the patient on Room Air or O2: 5L

Pain: Patient states his pain

is a 0 currently, as he is not
experiencing a
coughing/sneezing episode.

via nasal cannula

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

flat
loud

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 / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Unremarkable dentition. Teeth are straight and none are missing.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: clear white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Lung sounds are diminished in all lobes. Difficult to hear any adventitious sounds.
RUL: D
LUL: D
RML: D
LLL: D
RLL: D
Respirations are labored as patient is dyspneic upon physical exertion, including coughing and sneezing.
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze):
HR: 99 bpm PR: 0.12 QRS: 0.08 QT: 0.32 Rhythm: Sinus rhythm (Sometimes sinus tachycardia)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+ Femoral: 2+ Popliteal: 2+ DP: 2+ PT: 2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: N/A
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 08/30/2016)
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: Patient denies nausea or emesis.
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe:
GU
Urine output:
Clear
Cloudy
Color: Yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output:

without assistance

or

1350 mLs N/A

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

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]

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
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Patient deferred Romberg test (as he has difficulty moving about, especially after physical exertion with physical therapy. Patient
deferred testing of deep tendon reflexes as he advised he would like to rest. Patients gait is regular, but shuffling and his gait is not
smooth, as he is struggling to stand and ambulate for very long.

University of South Florida College of Nursing Revision September 2014

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior
to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds,
X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then include why
you expect it to be done and what results you expect to see.
Lab/Diagnostic Test
CT Chest WO Contrast:
1. Diffuse reticulation, traction
bronchiectasis and
bronchiolectasis, and
groundglass opacities in the
lower lobe, peripheral, and
basilar predominance.
Differential diagnosis includes
fibrotic nonspecific interstitial
pneumonia, atypical usual
interstitial pneumonia, or if the
patient has a history of
smoking desquamative
interstitial pneumonia.
2. Mediastinal
lymphadenopathy, is
nonspecific and likely reactive.
3. Slightly enlarged pulmonary
trunk, which can be seen in the
setting of pulmonary
hypertension.
4. Atherosclerosis and
coronary artery disease.

Dates
(08/27/2016, 0429)

Trend

Analysis

Shortly following
admission, patient
received a CT chest WO
contrast. This exam
demonstrated diffuse
pulmonary fibrosis and
was part of what aided in
diagnosing his idiopathic
pulmonary fibrosis. As a
follow-up and in
preparation for his
meeting before the lung
transplantation board, his
provider ordered a CT
chest angiogram c
contrast.

The results of the

patients original CT
chest WO contrast
demonstrated that he has
diffuse pulmonary
fibrosis of unknown
origin. As diffuse
pulmonary fibrosis is one
of the hallmarks of IPF,
this was part of what led
to his diagnosis.

Patients oxygen
saturation fluctuated
between 94% and 97%
when he was on 5L of
supplemental oxygen via
nasal cannula. Dips in his
oxygen saturation
followed any amount of
exertion, whether
emotional or physical, as
they led to tachypnea and
dyspnea.

Oxygen saturation levels

are directly affected by
patients ability to
perform effective gas
exchange. Regarding his
diffuse pulmonary
fibrosis, it is not
surprising that he has
compromise lung
capacity and, thus, suffers
from decreased activity
tolerance. Although the
supplemental oxygen
helped decrease his

O2 on Continuous Pulse Ox:

1. 95%

(08/30/2016, 0400)

2. 97%

(08/30/2016, 0814)

Normal (95 100%)

University of South Florida College of Nursing Revision September 2014

symptoms, it is not a
long-term solution to this
patients problems.
CO2:
1. 25 mEq/L

(08/29/2016, 0415)

2. 29 mEq/L

(08/30/2016, 0743)

Normal (23 29 mEq/L)

Patients CO2 levels were

within the normal range,
however, they were
trending upward. By the
morning of this interview,
his CO2 level was at the
upper end of the normal
range.

As CO2 levels are directly

related to the patients
ability to perform
effective gas exchange
and breathe off
systemic CO2, it is
expected that his CO2
levels would either
steadily climb or remain
relatively high as
patients lung function
deteriorates.

Patients Na+ levels were

slightly below the normal
range, however, they
trended upward and, by
the morning of this
interview, his level was
within the normal range,
having increased 7
mEq/L.

Patients oral intake

volume was greatly
decreased during his
hospital stay, as he
struggled with his dry
cough and sneezing
episodes. This decrease in
volume could explain his
increase in Na+ level.

Patients K+ levels
remained within the
normal range, however,
they were trending
downward by the
morning of this interview.
Over the course of a day,
his levels decreased 0.9
mEq/L.

Patient reported that he

ate potassium rich foods
such as bananas at home.
During his hospital stay,
his food intake was
limited as his restrictive
lung condition was
exacerbated. It is possible
that the decrease in his
K+ level could be
explained by this
discrepancy.

Patients blood glucose

levels were within the
acceptable range for his
hospital stay (though they
would technically be
considered high in

As patients oral intake

was decreased during his
hospital stay and he was
not receiving
supplemental dextrose via
his intravenous line, his

Sodium (Na+):
1. 133 mEq/L

(08/29/2016, 0415)

2. 140 mEq/L

(08/30/2016, 0743)

Normal (135 145 mEq/L)

Potassium (K+):
1. 4.9 mEq/L

(08/29/2016, 0415)

2. 4.0 mEq/L

(08/30/2016, 0743)

Normal (3.5 5.0 mEq/L)

Glucose:
1. 136 mg/dL

(08/29/2016, 0415)

2. 109 mg/dL

(08/30/2016, 0743)

Normal (70 100 mg/dL)

University of South Florida College of Nursing Revision September 2014

textbooks). Even so, his

blood glucose levels were
trending downward by
the morning of this
interview.

downward blood glucose

trend was expected. He
was not placed on bedside
glucose monitoring
because he was still
eating enough to maintain
his levels, nor is he a
diabetic and his labs were
being drawn each
morning.

Patients RBC levels

remained consistent.

Patients RBC levels were

within the realm of
reason. They were
technically slightly lower
than normal for men,
but they were not
alarmingly low. If
anything, the concern
would be that his RBC
levels would be elevated
due to his pulmonary
fibrosis, so his RBC
levels were considered
unremarkable by his
healthcare staff.

Patients Hgb levels

remained consistent.

According to patients
nursing staff, his Hgb
levels were not only
acceptable, but also
remarkable. This level is
important for his
healthcare team to
monitor, as it is a
significant factor in
determining patients
ability to carry oxygen
through his system. With
the patients already
compromised lung
function, it is important
that he is able to
maximize what gas
exchange he has available
to him.

Red blood cells (RBCs):

1. 4.35 million cells/mcL

(08/29/2016, 0415)

2. 4.38 million cells/mcL

(08/30/2016, 0743)

Normal (4.7 6.1 million

cells/mcL for men)

Hemoglobin (Hgb):
1. 13.2 g/dL

(08/29/2016, 0415)

2. 13.2 g/dL

(08/30/2016, 0743)

Normal(13.517.5g/dL)

Home Oxygen Evaluation:

University of South Florida College of Nursing Revision September 2014

Patient qualified for home

oxygen therapy, as his oxygen
saturation dropped to 85%
when he was removed from
his 5L of oxygen and dangling
at bedside.

(08/30/2016, 1432)

Patient qualified, per the

respiratory therapist, for
supplemental oxygen
therapy at home.

This result was expected,

as patient was diagnosed
with IPF and suffered
from restrictive lung
disease accordingly.

It would be expected that

the results of the patients
pulmonary function tests,
6-minute walk test, CT
angiogram with contrast
and ABGs will reflect his
compromised lung
function. Most likely, he
will demonstrate
exertional breathlessness,
compromised PFTs and
diffuse pulmonary
fibrosis in his CT. It is
possible that, by the time
patients ABGs are
drawn, his CO2 levels are
higher and he could be
slightly acidotic.

Analyses cannot be made

at this time, as these
tests/labs were not
performed yet. To the left
(under Trend),
however, are speculations
as to results that might be
expected due to the
patients condition.

Pending Labs/Tests:
1. 6-minute walk test
(Pending)
2. Pulmonary function tests
3. CT angiogram c contrast
4. Arterial blood gases (ABGs)

+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.)
Diet: MCLS (heart healthy)
Vitals: Patient on telemetry monitor as well as continuous pulse oximetry. Vitals documented Q4hours
Activity: Activity with assistance, walker, and supplemental oxygen via nasal cannula. (Bathroom privileges)
Consults: Dietitian (to address patients concerns about his recent rapid weight loss), physical therapy (to
evaluate his mobility and formulate a plan to prevent deconditioning), pastoral care (to help him complete an
advance directive as well as grant his wife power of attorney per patient request), lung transplant team (to
evaluate his candidacy for lung transplantation), respiratory therapy (to evaluate his qualifications for home
oxygen therapy), and social services/social worker (to aid patient in coordinating services necessary at home
while awaiting potential transplantation.
Procedures/Scheduled diagnostic tests:
o 6-minute walk test: Patient is scheduled for traditional 6-minute walking test tomorrow (08/31/2016)
in order to evaluate his activity tolerance.
o Pulmonary function tests (PFTs): Patient is scheduled for pulmonary function tests tomorrow
(08/31/2016) in order to evaluate his lung volume and capacity, lung flow rates and the effectiveness of
his gas exchange. These tests will measure his tidal volume (VT), minute volume (MV), residual
volume, forced expiratory volume (FEV), vital capacity (VC), functional residual capacity (FRC), total
lung capacity, forced vital capacity (FVC), forced expiratory volume (FEV), forced expiratory flow
University of South Florida College of Nursing Revision September 2014

(FEF), and peak expiratory flow rate (PEFR).

o CT angiogram with contrast: Patient is scheduled for chest CT angiogram with contrast later today
(08/31/2016) in order to follow-up on the original chest CT angiogram without contrast.
o Home oxygen evaluation: Patient received a home oxygen evaluation today by respiratory therapy
while being interviewed for the PAT. Patient was removed from supplemental oxygen and dangled at
the bedside. He remained on continuous pulse oximetry and his oxygen saturation decreased to 85%
within a matter of moments, qualifying him for home oxygen therapy.
Lung Transplantation Board Meeting: Patient scheduled for a meeting before the lung transplantation
board/committee on Thursday, 09/01/2016, following his array of tests. Prior to this meeting, the lung
transplantation board will review his tests and during this meeting, patient will plead his case for lung
transplantation. Barring any complications, a decision will be made as to whether or not patient qualifies as a
candidate for lung transplantation.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
1st Priority Nursing Diagnosis: Ineffective breathing pattern related to compromised pulmonary function as evidenced by dyspnea, tachypnea (seen
on monitor and observed during physical assessment) and oxygen desaturation (seen on monitor).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
By discharge, patient will
1. Monitor respiratory rate, depth,
1. When respiratory rate exceeds
As this is a long-term goal, it
demonstrate a breathing pattern
and ease of respiration. (Normal
30 breaths/min, along with other
cannot be evaluated on the day care
that supports blood gas results
respiratory rate is 10 to 20
physiological measures, a study
was provided. Even so, patient was
within the patients normal
breaths/min in the adult.)
demonstrated that a significant
beginning to learn how to breathe
parameters.
2. Note pattern of respiration. If
physiological alteration existed.
more effectively and address his
patient is dyspneic, note what
2. When a patient becomes
tachypnea. This goal would be
seems to cause the dyspnea, the
dyspneic and the breathing pattern evaluated closer to his discharge.
way in which the patient deals with becomes ineffective, it is important
the condition, and how the dyspnea that he recognizes this and is able
resolves or gets worse.
to focus and reestablish and
3. Ensure that patient in acute
effective breathing pattern. If he is
dyspneic rate has received any
unable to, it is important that he is
ordered medications, oxygen, and
able to call for help in resolving the
any other treatment needed.
dyspnea.
4. Administer oxygen as ordered.
3. Ensuring that the patient has
5. Monitor oxygen saturation
received the appropriate
continuously using pulse oximetry. interventions for dyspnea will
Note blood gas results as available. enable him to establish a breathing
pattern compatible with effective
gas exchange.
4. Oxygen administration has been
shown to correct hypoxemia, which
causes dyspnea.
5. An oxygen saturation of less
than 90% (normal 95-100%) or a
partial pressure of oxygen less than
80 mmHg (normal 80-100 mmHg)
indicates significant oxygenation
problems.
By the end of the 10-hour shift,
1. Note pattern of respiration. If
1. When a patient becomes
By the end of the 10-hour shift,
patient will demonstrate ability to
patient is dyspneic, note what
dyspneic and the breathing pattern patient met the goal and was able
University of South Florida College of Nursing Revision September 2014

perform pursed-lip breathing and

controlled breathing.

seems to cause the dyspnea, the

way in which the patient deals with
the condition, and how the dyspnea
resolves or gets worse.
2. Note use of accessory muscles,
nasal flaring, retractions,
irritability, confusion, or lethargy.
3. Using touch on the shoulder,
coach the patient to slow
respiratory rate, demonstrating
slower respirations; making eye
contact with the patient; and
communicating in a calm,
supportive fashion.
4. Teach pursed-lip and controlled
breathing techniques.
5. Support the patient in using
pursed-lip breathing and controlled
breathing techniques.
6. Encourage the patient to take
deep breaths at prescribed intervals
and do controlled coughing.

By the end of the 10-hour shift,

patient will identify and avoid
factors that exacerbate episodes of
ineffective breathing patterns.

1. Assess cause of hyperventilation

by asking patient about current
emotions and psychological state.
2. Schedule rest periods before and
after activity.
3. Help the patient with chronic
respiratory disease to evaluate
dyspnea experience to determine if
similar to previous incidences of

becomes ineffective, it is important

that he recognizes this and is able
to focus and reestablish and
effective breathing pattern. If he is
unable to, it is important that he is
able to call for help in resolving the
dyspnea.
2. These symptoms signal
increasing respiratory difficulty
and increasing hypoxia.
3. The nurses presence,
reassurance, and help in controlling
the patients breathing can be
beneficial in decreasing anxiety.
4. Studies have demonstrated that
pursed-lip breathing was effective
in decreasing breathlessness and
improving respiratory function.
5. Pursed-lip breathing results in
increased use of intercostal
muscles, decreased respiratory rate,
increased tidal volume, and
improved oxygen saturation levels.
A systematic review found pursedlip breathing effective in
decreasing dyspnea.
6. Controlled breathing will be
effective in decreasing dyspnea.
1. Assessing the patients current
emotions and psychological state
enables the patient to focus on
breathing and decreased his
dyspnea.
2. Respiratory patients with
dyspnea are easily exhausted and
need additional rest.
3. The focus of attention on

University of South Florida College of Nursing Revision September 2014

to demonstrate pursed-lip and

controlled breathing.

By the end of the 10-hour shift,

patient met the goal and was able
to identify factors that were
exacerbating his
dyspneic/tachypneic episodes. He
was able to address these and
increase his oxygen saturation.

dyspnea and to recognize that he

made it through those incidences.
Encourage the patient to be selfreliant if possible, use problemsolving skills, and maximize use of
social support.
4. Assist the patient and family
with identifying other factors that
precipitate or exacerbate episodes
of ineffective breathing patterns
(i.e., stress, allergens, stairs,
activities that have high energy
requirements).

sensations of breathlessness has an

impact on judgment used to
determine the intensity of the
sensation.
4. Awareness of precipitating
factors helps patients avoid them
and decreases risk of ineffective
breathing episodes.

2nd Priority Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by abnormal heart rate response to
activity, exertional discomfort, exertional dyspnea, verbal report of fatigue, and verbal report of weakness.

Patient Goals/Outcomes
By discharge, patient will
participate in prescribed physical
activity with appropriate changes
in heart rate, blood pressure, and
breathing rate.

Nursing Interventions to Achieve

Goal
1. When getting a patient up,
observe for symptoms of
intolerance such as nausea, pallor,
dizziness, visual dimming, and
impaired consciousness, as well as
changes in vital signs.
2. Monitor and record the patients
ability to tolerate activity: note
pulse rate, blood pressure, monitor
pattern, dyspnea, use of accessory
muscles, and skin color before,
during, and after the activity. If the
following signs and symptoms of
cardiac decompensation develop,
activity should be stopped
immediately: onset of chest
discomfort or pain, dyspnea,
palpitations, excessive fatigue,
lightheadedness, confusion, ataxia,

Rationale for Interventions

Provide References
1. When an adult rises to the
standing position, blood pools in
the lower extremities; symptoms of
central nervous system
hypoperfusion may occur,
including feelings of weakness,
nausea, headache, lightheadedness,
dizziness, blurred vision, fatigue,
tremulousness, palpitations, and
impaired cognition.
2. The symptoms named to the left
are symptoms of intolerance to
activity and continuation of activity
may result in patient harm.
3. Assistive devices can help
increase mobility.
4. The 6-minute walk test predicted
mortality in COPD patients.

University of South Florida College of Nursing Revision September 2014

Evaluation of Goal on Day Care

is Provided
As this is a long-term goal, it could
not be evaluated on the day care
was provided. Patient will continue
to work with PT and this goal will
be evaluated again closer to his
discharge.

By the end of the 10-hour shift,

patient will verbalize an
understanding of the need to
gradually increase activity based
on testing, tolerance, and
symptoms.

pallor, cyanosis, nausea, or any

peripheral circulatory insufficiency,
dysrhythmia, exercise hypotension,
excessive rise in blood pressure,
inappropriate bradycardia, or
increased heart rate.
3. Obtain any necessary assistive
devices or equipment needed
before ambulating the patient (e.g.
walkers, canes, crutches, portable
oxygen).
4. If the patient is able to walk and
has chronic obstructive pulmonary
disease (COPD), use the traditional
6-minute walk distance to evaluate
ability to walk.
1. When appropriate, gradually
increase activity, allowing the
patient to assist with positioning,
transferring, and self-care as
possible. Progress from sitting in
bed to dangling, to standing, to
ambulation. Always have the
patient dangle at the bedside before
trying standing to evaluate for
postural hypotension.
2. Instruct the patient to stop the
activity immediately and report to
the nurse/provider if the patient is
experiencing the following
symptoms: new or worsened
intensity or increased frequency of
discomfort; tightness or pressure in
chest, back, neck, jaw, shoulders,
and/or arms; palpitations;
dizziness; weakness; unusual and
extreme fatigue; excessive air

1. Postural hypotension is
especially common in the elderly.
2. These are common symptoms of
angina and are caused by a
temporary insufficiency of
coronary blood supply. Symptoms
typically last for minutes as
opposed to momentary twinges. If
symptoms last longer than 5-10
minutes, the patient should be
evaluated by a physician. Pulse rate
and arterial blood oxygenation
indicate cardiac/exercise tolerance;
pulse oximetry identifies hypoxia.
3. Oxygen therapy can improve
exercise ability and long-term
administration of oxygen can
increase survival in COPD patients.
4. Both physical and emotional rest
help lower arterial pressure and
reduce the workload of the

University of South Florida College of Nursing Revision September 2014

By the end of the 10-hour shift, this

goal was met and the patient was
able to verbalize the need to take
gradual steps in increasing his
activity with PT and once he
returned home.

By discharge, patient will

demonstrate increased tolerance to
activity.

hunger.
3. Ensure that the chronic
pulmonary patient has oxygen
saturation testing with exercise.
Use supplemental oxygen to keep
oxygen saturation 90% or above or
as prescribed with activity.
4. Allow for periods of rest before
and after planned exertion periods
such as meals, baths, treatments,
and physical activity.
5. Assess the home environment
for factors that contribute to
decreased activity tolerance such as
stairs or distance to the bathroom.
Refer to occupational therapy, if
needed, to assist the patient in
restructuring the home and ADL
patterns.
6. Refer to physical therapy for
strength training and possible
weight training, to regain strength,
increase endurance, and improve
balance. If the patient is
homebound, the physical therapist
can also initiate cardiac
rehabilitation.
1. Refer to physical therapy for
strength training and possible
weight training, to regain strength,
increase endurance, and improve
balance. If the patient is
homebound, the physical therapist
can also initiate cardiac
rehabilitation.
2. Consider a dietitian referral to
assess nutritional needs related to

myocardium.
5. During hospitalization, patients
and families often estimate energy
requirements at home inaccurately
because the hospitals availability
of staff support distorts the level of
care that will be needed.
6. Following hospitalization,
patients may be deconditioned and
need strength training to increase
activity tolerance.

1. Physical therapy can help

evaluate the patients needs and
recommend/provide strength
training and weight training if
possible.
2. Providing nutrition early helps
maintain muscle and immune
system function, and reduce
hospital length of stay.
3. Patients who were living

University of South Florida College of Nursing Revision September 2014

As this is a long-term goal, it could

not be evaluated on the day care
was provided. The patient,
however, will continue working
with PT to increase his activity
tolerance. This goal will be
evaluated closer to patients
discharge.

activity intolerance; provide

nutrition as needed.
3. Provide emotional support and
encouragement to the patient to
gradually increase activity. Work
with the patient to set mutual goals
that increase activity levels. Fear of
breathlessness, pain, or falling may
decrease willingness to increase
activity.
4. Teach the patient/family the
importance of and methods for
setting priorities for activities,
especially those having a highenergy demand (e.g. home/family
events). Instruct in realistic
expectations.

independently prior to
hospitalization may experience
frustration and anxiety over
decreased activity tolerance.
4. Teaching patients to prioritize
activities will allow them to
maximize their energy in order to
promote their independence and
ability to participate in desired
activities.

3rd Priority Nursing Diagnosis: Fear related to threat to state of well-being and potential death as evidenced by patient report
of anxiety about his imminent meeting in front of the transplant board, patient report of his fear that he would never be able to
return to work.

University of South Florida College of Nursing Revision September 2014

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: Patient awaiting transplant coordinating committees decision on whether or not he is a candidate for lung transplant. Social
services is involved in helping coordinate his care and any home health care or outpatient tests he will need to have done.
* Dietary Consult: Patient should receive a dietary consult to help him choose a diet that is appropriate for his condition. He and his wife are
concerned about his recent rapid weight loss (15 pounds in approximately 1 month).
PT/ OT: Patients mobility was evaluated by physical therapy. Physical therapist advised patient that they would follow him throughout his stay
and take measures to prevent against further deconditioning of his lungs as well as deconditioning of his muscles.
RT: Respiratory therapist performed patients Home O2 evaluation during the PAT and was able to determine that he does qualify for home O2.
Respiratory is also monitoring his status, as he is dyspneic and on 5L of oxygen via nasal cannula. Patient will also be doing a pulmonary function
test as well as a 6-minute walk test tomorrow (08/31/16) in preparation for the transplant board meeting on Thursday (09/01/16).
Pastoral Care: Pastoral care was consulted, as patient requested a chaplain to help make his wife his power of attorney. Patient also expressed
interest in completing an advance directive.
Durable Medical Needs
Transplant Team: Transplant committee/team/board has been consulted and is actively following the patients case. They are reviewing his lab
results, tests, condition and case in order to decide whether or not he qualifies as a candidate for lung transplant.
F/U appointments: Patient may need follow up appointments, depending on the transplant teams decision.
Med Instruction/Prescription
Are any of the patients medications available at a discount pharmacy? Yes
No
Rehab/HH
Palliative Care: Patient may request palliative care to help him find his new baseline with his new diagnosis.

University of South Florida College of Nursing Revision September 2014

References
Ackley,B.J.,&Ladwig,G.B.(2014).Nursingdiagnosishandbook:Anevidencebasedguidetoplanningcare
(10thed.).MarylandHeights,MO:MosbyElsevier.
Epocrates,Inc.(2016).Epocrates(Version16.6)[Mobileapplicationsoftware].Retrievedfrom
http://itunes.apple.com
Halter,M.J.(2014).Relevanttheoriesandtherapiesfornursingpractice.Varcarolisfoundationsofpsychiatric
mentalhealthnursing(pp.2224).SaintLouis:Elsevier.
Tighe,R.M.,Meltzer,E.B.,Noble,P.W.(2015).Idiopathicpulmonaryfibrosis.InM.Grippi,J.Elias,J.
Fishman,R.Kotloff,A.Pack,R.Senior,&M.Siegel(Eds.),Fishmanspulmonarydiseasesand
disorders,5thedition.RetrievedSeptember02,2016
http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?
bookid=1344&Sectionid=81190295
UnitedStatesDepartmentofAgriculture.(2016,Jan7).Choosemyplate.Retrievedfrom
http://www.choosemyplate.gov/MyPlate

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University of South Florida College of Nursing Revision September 2014