UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jessica Rowe

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: LRMC-VBSN

1 PATIENT INFORMATION
Patient Initials:

S.B

Age:

34

Gender:

Male

Marital Status: Married

Primary Language: English

Level of Education: Unable to obtain
Occupation (if retired, what from?):

Assignment Date: June 7 2016

Admission Date: June 2, 2016

Primary Medical Diagnosis Altered Mental Status
with aggitation
Other Medical Diagnoses: (new on this admission)
Drug overdose

Number/ages children/siblings: None/ unable to obtain

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

Code Status: Full

Living Arrangements: Lives at home with wife

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

Culture/ Ethnicity /Nationality: White Non-hispanic

Religion: Christian

Type of Insurance: Amerigroup Medicaid

1 CHIEF COMPLAINT:
Altered Mental status with agitation and vomiting black material

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) The patient was supposed to be on a fishing trip with friends. He was picked up from a Hotel where he was staying
after a friend called 911 stating that he had altered mental status and was agitated as well as vomiting some black type of
material. Pt has a history of chronic back pain and takes opiates for his pain. Upon arrival to the ED he was able to
communicate and he denied the use illicit drugs and denied running out of his opiates which would have led to withdrawal
symptoms. The Drug screen came back positive for benzodiazepines, amphetamines, and opiates. In the ER the patient
developed a fever, and noisy respirations, he was also diaphoretic and tachycardic, he was suspected to have aspirated.
Lab testing showed leukocytosis and renal failure. After administration of opiates the patient showed no improvement
and was sedated and intubated. Head CT was negative, Ct of abdomen and pelvis showed basilar lung infiltrates versus
atelectasis. Pt was admitted to ICU for further care.

University of South Florida College of Nursing Revision September 2014

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

Father

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Cause
of
Death
(if
applicable
)
COPD

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

Unknown
unknown

Environmental
Allergies

Operation or Illness
Chronic back pain
Back fusion
Tonsillectomy
Skin grafting with chronic left ankle ulcer

Alcoholism

Date

Mother
Brother
Sister
relationship
relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
date unknown
Adult Tetanus (Date) Is within 10 years?
Date unknown
Influenza (flu) (Date) Is within 1 years?
Unknown
Pneumococcal (pneumonia) (Date) Is within 5 years?
Unknown
Have you had any other vaccines given for international travel or
occupational purposes? Please List
Unknown
If yes: give date, can state U for the patient not knowing date received
University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
IV contrast

Type of Reaction (describe explicitly)

Reactions not listed/ patient intubated

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment). Aspiration is the passage of fluid and solid particles into the lung. It tends to occur in individuals
whose normal swallowing mechanism and cough reflex are impaired by central or peripheral nervous system
abnormalities. Predisposing factors include an altered level of consciousness caused by substance abuse,
sedation, or anesthesia; seizure disorders; cerebrovascular accident; and neuromuscular disorders that cause
dysphagia. The right lung, particularly the right lower lobe, is more susceptible to aspiration than the left lung
because of the branching angle of the right main stem bronchus is straighter than the branching angle of the left
main stem bronchus.
The aspiration of large food particles or foreign bodies can obstruct a bronchus, resulting in bronchial inflammation and collapse of
airways distal to the obstruction. Clinical manifestations include the sudden onset of choking, coughing, vomiting, dyspnea, and
wheezing. If the aspirated solid is not identified and removed by bronchoscopy, a chronic local inflammation develops that may lead
to recurrent infection and bronchiectasis. Once the pathologic process has progressed to bronchiectasis, surgical resection of the
affected area is usually required.
Aspiration of acidic gastric fluid (PH <2.5) may cause severe pneumonitis (lung inflammation). Bronchial damage includes
inflammation, loss of ciliary function, and bronchospasm. In the alveoli, acidic fluid damages the alveolocapillary membrane,
allowing plasma and blood cells to move from the capillaries into the alveoli, resulting in hemorrhagic pneumonitis. The lung becomes
stiff and noncompliant as surfactant production is disrupted, leading to further edema and collapse.

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

Name

Route

Inhaled

Concentration 2.5 mg

Dosage Amount

0.5 ML

Frequency Q 6 hrs

Pharmaceutical class
Hospital
adrenergics
Indication
bronchodilator to control or prevent reversible airway obstruction
Adverse/ Side effects
paradoxical bronchospasm, chest pain, palpitations, nervousness, restlessness, tremor,
Nursing considerations/ Patient Teaching:
Instruct the patient to contact heath care professionals if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness,
palpitations, or chest pain; Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth and to clan mouthpiece with water once a
week. Instruct patient to notify health care professionals if there is no response to the usual dose or if contents of one canister are used in less than 2 weeks.
Asthma and treatment regimen should be re-evaluated and corticosteroids should be considered. Need for increased used to treat symptoms indicates decrease
in asthma control and need to re-evaluate patients therapy.

University of South Florida College of Nursing Revision September 2014

Name Cefepime

Concentration 1,000 mg, 50 ML

Route IBPB

Dosage Amount 100ml/hr

Frequency Q 12 Hrs

Pharmaceutical class
Hospital
Fourth generation cephalosporin
Indication
Treatment of MRSA in left ankle Ulcer
Adverse/ Side effects
Seizures, C. Diff-associated diarrhea, rashes, Pain at IM site, Phlebitis at IV site, Anaphylaxis, pruritis
Nursing considerations/ Patient Teaching
Advise patient to report signs of superinfection (furry overgrowth on tongue, vaginal itching or discharge, loose or foul smelling stools) and allergy; Instruct
patient to notify heath care professionals if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea
without consulting health care professionals
Name Docusate

Concentration

100 mg

Route OG tube

Dosage Amount 10 ML

Frequency TID

Pharmaceutical class
Hospital
Stool Softners
Indication
Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery)
Adverse/ Side effects
Mild cramps, diarrhea, throat irritation, rashes
Nursing considerations/ Patient Teaching
Do not confuse Colace with Cozaar, do not confuse dulcolax (docusate sodium) with Dulcolax (bisacodyl). This medication does not stimulate intestinal
peristalsis, stimulate laxative may be required for constipation.
Advise patients that laxititves should be used only for short-term therapy. Long-term therapy amy cause electrolyte imbalance and dependence. Advise patient
not to use laxatives when abdominal pain, nausea, vomiting, or fever is present. Do not take docusate witin 2 hours of other laxatives.
Name

Gabapentin

Concentration 300 mg

Route OG tube

Dosage Amount 1 Cap

Frequency TID

Pharmaceutical class
Hospital
Mood Stabalizers
Indication
Partial seizures, anxiety, drug withdrawl
Adverse/ Side effects
Suicidal thoughts, confusion, depression, dizziness, drowsiness, hostility, hypertension, anorexia, gingivitis, rhabdomyolysis, ataxia, multiorgan hypersensitivity
reactions, facial edema
Nursing considerations/ Patient Teaching
Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts, behavior or depression
Instruct patient to take medication exactly as directed. Patients on TID dosing should not exceed 12 hours in between doses. If missed dose take as soon as
possible but do not double dose, if close to time for next dose take the dose immediately then take the next dose 2 hours later. Do not discontinue abruptly, may
cause an increase in frequency of seizures. Do not take within 2 hours of antacid. May cause dizziness or drowsiness, avoid driving or operating heavy
machinery until effects are known. Notify health care providers of any thoughts of suicide or dying, attempts to commit sucide. New or worse depression, new
or worse anxiety, feeling very agitated or restless, panic attacks, trouble sleeping, new or worse irritability, acting aggressive, being angry or violent. Acting on
dangerous impulses, an extreme increase in activity or talking, or other unusual changes in behavior or mood occur.

Name Heparin

Concentration 5,000 U

Route Subcutaneous injection

Dosage Amount 1 Ml
Frequency q 8 hrs

Pharmaceutical class
Hospital
antithrombotic
Indication
Prophylaxis and treatment of various thromboembolic disorders, venous thromboembolism, pulmonary emboli, atrial fibrillations with embolization, acute and
chronic consumptive coagulopathies, peripheral arterial thromboembolism
Adverse/ Side effects
Bleeding, heparin-induced throm,bocytopenia (HIT) anemia, pain at injection site, fever, hypersensitivity
Nursing considerations/ Patient Teaching
Asses for signs of bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, black tarry stools, hematuria, fall in hematocrit or BP), notify heath
care providers if these occur. Monitor platelet count every 2-3 days throughout therapy.
Advise patient to report any symptoms of unusual bleeding or bruising to heath care professionals immediately. Instruct patient not to take medications
containing aspirin or NSAIDS while on heparin therapy. Avoid Im injections and activities leading to injury and to use a soft toothbrush and electric razor
during heparin therapy.

Name Levofloxacin

Concentration 750mg/150ml

Dosage Amount 100ml/hr

University of South Florida College of Nursing Revision September 2014

Route

IVPB

Frequency

q 24 Hrs

Pharmaceutical class
Hospital
fluroquinolones
Indication
Treatment of uncomplicated and complicated skin and skin structure infections MRSA in wound and Naiirs
Adverse/ Side effects
Elevated intracranial pressure, seizures, agitation, depression, hallucinations, insomnia, nightmares, Torsade de pointes, hepatotoxicity, C. Diff-associated
diarrhea, nausea, phlebitis at IV site, tendonitis, tendon rupture, anaphylaxis
Nursing considerations/ Patient Teaching
Instruct patient to take medication as directed at evenly spaced times and to finish drug completely even if feeling better. Take missed dose as soon as possible,
unless almost time for next dose, do not double doses. Maintain fluid intake of at least 1500-2000mL/day to prevent crystlluria. Antacids or medications
containing calcium, aluminium, iron, and zinc will decrease absorption and should not be taken within 4 hr before and 2 hr after taking this medication. Notify
health care professional of any personal or family history of QTs prolongation or proarrhythimic conditions such as recent hypokalemia, significant
bradycardia, or recent myocardial ischemia or if fainting spells or palpitations occur. Patients with this history should not receive levofloxacin.

Name Reglan

Concentration 10mg

Route IV Push

Dosage Amount 2 ml
Frequency q 6hrs

Pharmaceutical class
Hospital
antiemetics
Indication
Facilitation of small bowel intubation in radiographic procedures, treatment and prevention of postoperative nausea and vomiting when nasogastric suctioning
is undesirable
Adverse/ Side effects
Drowsiness, extrapyramidal reactions, restlessness, neuroleptic malignant syndrome, tartive dyskinesia, constipation, diarrhea,
Nursing considerations/ Patient Teaching
Instruct patient to take metoclopramide as directed. Take missed doses as soon as remembered if not almost time for next dose. Advise patient to read the
medication guide before starting therapy and with each RX refill in case of changes. May cause drowsiness caution patient to avoid driving or other activities,
requiring alertness until response to medication is known. Avoid concurrent use of alcohol or other CNS depressants while taking this medication.
Name

Morphine

Route

OG tube

Concentration 300mg

Dosage Amount 2 tabs

Frequency q 6 hrs

Pharmaceutical class
Hospital
Opioid agonists
Indication
Moderate to severe chronic pain in opioid tolerant patients requiring use of daily, around the clock long term opioid treatment and for which alternative
treatment options are inadequate
Adverse/ Side effects
Confusion, sedation, dizziness, blurred vision, respiratory depression, hypotension, constipation, nausea, urinary retention, flushing, itching, sweating
Nursing considerations/ Patient Teaching
Instruct patient on how and when to ask for pain medication, may cause drowsiness or dizziness, advise patient to call for assistance when ambulating or
smoking and to avoid driving or other activities until response is known. Change positions slowly to minimize orthostatic hypotension. Avoid use of alcohol or
other CNS depressants. Explain to the patient and family how and when to administer morphine and how to properly care for infusion pump.
Name Vancomycin + d5w
Route IV

Concentration 1250mg/12.5 ml

Dosage Amount

175 ml/hr

Frequency q 8 hrs

Pharmaceutical class
Hospital
Anti-infective
Indication
Treatment of potentially life-threatening infections when less toxic anti-infections are contraindicated, particularly useful in staphylococcal infections
Soft tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin
Adverse/ Side effects
Nephrotoxicity, ototoxicity, hypotension, phlebitis, anaphylaxis, rashes, nausea, vomiting
Nursing considerations/ Patient Teaching
Advising patients on oral vancomycin to take as directed. Take missed dose as soon as remembered, do not double up on doses. Instruct patient to report signs
of hypersensitivity, tinnitus, vertigo, or hearing loss. Patients with history of rheumatic heart disease or valve replacement need to be taught importance of
using antimicrobial prophylaxis prior to invasive dental or medical procedures

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?
Jevity
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
According to my plate the patient should have 6 ounces of
protein, 2 cups of fruit, 3 cups of vegetables, 7 ounces of
grains, 3 cups of dairy, and 6 teaspoons of oil daily.
According to the patients 24 hour diet recall he gets
enough protein, and vegetables, he needs to add fruit to his
diet preferably with breakfast or as a snack. He needs to
incorporate more dairy into his diet to obtain adequate
amounts of calcium.
Breakfast: 2 eggs, bacon, toast
Lunch: chicken cesar salad,
Dinner: baked porkchop, mashed potatoes, steamed
broccoli
Snacks: chips,
Liquids (include alcohol): coffee x2 cups, water, coke 20
0z.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Unable to obtain, pt is intubated
How do you generally cope with stress? or What do you do when you are upset? Unable to obtain, pt is intubated

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) Unable to
obtain, Pt is intubated

+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.

University of South Florida College of Nursing Revision September 2014

Have you ever felt unsafe in a close relationship? Unable to obtain _______________________________________
Have you ever been talked down to? Unable to obtain__ Have you ever been hit punched or slapped? Unable to obtain_
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Unable to obtain If yes, have you sought help for this?
Are you currently in a safe relationship? Unable to obtain

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Intimacy vs Isolation: the capacity to commit himself to concrete affiliations and partnerships and to develop the
eithical strength to abide by such commitments. Isolation is the avoidance of intimacy, the task at this stage is to develop a
commitment to work and relationships. Failure to do so will result in impersonal relationships and difficulty with maintaining a job.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: I believe
that my patient is in the intimacy stage because he has shown his ability to make a commitment to a personal relationship, he is
married.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
This hospitalization may impact his relationship with his wife because instead of fishing as he told her that he was doing, he was a
hotel with friends partying. This may also impact whatever job he had due to the fact that he was in the hospital so long and that his
drug toxicity came back positive for illicit drugs.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Unable to obtain, pt is inubated

What does your illness mean to you? Unable to obtain, pt is intubated

+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? _unable to obtain, pt is intubated ____________________
Are you aware of ever having a sexually transmitted infection? Unable to obtain, pt is intubated _______________
Have you or a partner ever had an abnormal pap smear? Unable to obtain, pt is intubated _____________________
Have you or your partner received the Gardasil (HPV) vaccination? Unable to obtain, pt is intubated ________
Are you currently sexually active? Unable to obtain____ If yes, are you in a monogamous relationship? Unable to obtain

University of South Florida College of Nursing Revision September 2014

When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Unable to obtain_____________
How long have you been with your current partner? Unable to obtain___________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? Unable to obtain
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Unable to obtain

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? Unable to obtain, pt is intubated
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? Unable to obtain
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? Unable to obtain

How much?(specify daily amount)

Unable to obtain

Yes
No
For how many years? unknown
years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Unable to obtain

Yes
No
For how many years?
(age

thru

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
If so, what? According to clinical notes, pt denies use of illicit drugs but drug toxicity came back positive for
amphetimines
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks Unable to obtain

5. For Veterans: Have you had any kind of service related exposure? NA

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other: chronic ulcer on left ankle

Be sure to answer the highlighted area

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

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other: pt intubated has not had a BM since
admission

Chills with severe shaking

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

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other: pt intubated

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
x/day
Bladder or kidney infections
Pt is intubated/ with foley catheter
x/day
x/year

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other: pt intubated

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? June 7 2016
Other: pt intubated

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? June 2

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?
Date of last prostate exam?
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: pt intubated

Musculoskeletal
Injuries or Fractures
Weakness
Pain, chronic back
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

10

2016
Other:

Other: pt intubated

Other: pt intubated, unable to obtain

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

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Pt is intubated, unable to obtain

Any other questions or comments that your patient would like you to know? Pt is intubated, unable to obtain

University of South Florida College of Nursing Revision September 2014

11

10 PHYSICAL EXAMINATION:
General Survey:

Temperature: (route
taken?) 36.4 C

Height
Pulse 68
Respirations 17
SpO2 100

Weight 91.1 kg
BMI
Blood Pressure: (include location)
134/72
Is the patient on Room Air or O2 pt is

Pain: (include rating and

location) uanable to selfreport

intubated on a ventilator. 40% FIO2

Overall Appearance: [Dress/grooming/physical handicaps/eye contact]

clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Pt is well groomed, dressed appropriate for setting, pt is intubated so does not make eye contact
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Sedated, easy to stimulate, agitation
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction intubated, unable to assess
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other: sedated, easily stimulated but can calm by talking to him
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
Chronic Ulcer on Left ankle, covered by bandage

flat
loud

Central access device Type: 20 g PIV Left forearm, 18 g Date Right forearm inserted:
Fluids infusing?
no
yes - what? Propofol 1,000 mg titrate, Midazolam 100mg IV titrate, Fentanyl + 0.9 % sodium
chloride 2500 mcg IV Titrate, Dexmedetomindine 1,000 mcg + 0.9% sodium chloride 240 ml IVPB titrate
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 /2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Unchecked boxes unable to obtain
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL clear
LUL Clear
RML slightly diminished LLL diminished
RLL diminished

Chest expansion

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

University of South Florida College of Nursing Revision September 2014

12

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

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: bilateral hands +2
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(78mm) ]

Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: unknown, had not had a BM since admission, checked for impaction and was not impacted
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present: had documentation in medical record stated that pt vomited black looking
material prior to intubation
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Bowel sounds hypoactive
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

mLs N/A

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _______ RUE _______ LUE _______ RLE & _______ in LLE

unable to assess

[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 intubated, unable to assess

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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):
Portable CXR 6/5/16 tip of ET tube is 4.9 above Corina, NG tube below diaphragm, right basilar atelectasis
Wound culture/csf 6/3/16 CSF negative, Positive MRSA Nares and wound
Portable CXR 6/7/16 S/P intubation. ET tube 2 cm above corina, OG tube is in stomach. Lungs are
underexpanded with hazy pleural-parenchymal opacities in mid-lower lung zones bilaterally.
Lab
NA+
K
BUN
HGB
HCT

Dates
6/7/16, 6/10/16, 6/11/16,
6/13/16
6/7/16, 6/10/16, 6/11/16,
6/13/16
6/7/16, 6/10/16, 6/11/16,
6/13/16
6/7/16, 6/10/16, 6/11/16,
6/13/16
6/7/16, 6/10/16, 6/11/16,
6/13/16

Trend
143, 140, 141, 142

Analysis

4.3, 4.0, 3.6, 3.6

6, 8, 11, 14
11.4, 11.7, 12.1, 12.6

Hgb is low but

continuing to trend up

34.6, 34.8, 36.1, 37.8

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: Respiratory comes to give breathing

treatments every 6 hours. Turn patient every 2 hours to prevent pressure ulcers. Currently administering meds
for GI prophylaxis, pt has not had a BM since admission, checked for impaction and pt is not impacted. Oral care
to help prevent pneumonia from being ventilated. Wound care consulted on left ankle for chronic ulcer.

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

1. Ineffective breathing pattern related to prolonged ventilator dependence AEB apnea when off ventilator
2. At risk for injury r/t environmental conditions interacting with clients adaptive and defensive resources
3. At risk for entry of gastrointestinal fluids into the tracheobronchial passage as evidenced by delayed gastric emptying and
increased gastric residual
4.Risk for acute confusion due to impaired cognition, metabolic abnormalities, pain, pharmaceutical agents, opioids,
substance abuse
5.

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 15 CARE PLAN
Patient Goals/Outcomes
The patient will demonstrate a
breathing pattern that supports
blood gas results within the normal
parameters

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Monitor respiratory and
An oxygen saturation of less than
oxygenation status as necessary
90% or a partial pressure of oxygen
Obtain Arterial blood gas
less than 80 mmHg indicates
significant oxygenation problems
Turning and coughing

The patient will report ability to

breathe comfortably

Encourage slow, deep breathing

The patient will remain free of

injuries

Ask the family to stay with the

patient from pulling out tubes

The patient will demonstrate

behaviors that decrease the risk for
injury

Avoid use of restraints if at all

possible, obtain physicians order if
restraints are necessary

Evaluation of Goal on Day Care

is Provided
The patient demonstrates breathing
pattern that supports blood gas
results within the normal
parameters
The patient is able to breathe
comfortably

Intubated/sedated patients can

wake up confused and pull out
endotracheal tubes

Patient remains free of injury

The patient demonstrates behaviors
that decrease risk for injury

The use of restraints has been

associated with serious injuries

Increased observation of the patient

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Include a minimum of one

Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
xRehab/ HH
Suggest that the patient attend a support group or get rehab for use of opiates and illicit drugs
Palliative Care

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References

Ackley, Betty J. & Ladwig, Gail B. (2014), Pp.129-130, 348-350, 792-795 Nursing Diagnosis Handbook: An
evidenced based guide to planning care. 10th ed.
Huether, Sue E. & McCance, Kathryn L. (2012), Pp. 682 Understanding Pathophysiology 5th ed.
Treas, Leslie S. & Wilkinson, Judith M. (2014), Pp. 163 Basic Nursing: Concepts, Skills, and Reasoning

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