UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: E. Clare Maffett

MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 03/10/16

Agency: TGH

Patient Initial: H.G.

Age: 42

Admission Date: 03/08/16

Gender: Female

Marital Status: Married

Primary Medical Diagnosis

Primary Language: English

Level of Education: College

Myasthenia Gravis
Small Fiber Neuropathy
Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): RN at All Childrens Hospital on

medical leave
Number/ages children/siblings: 1 sister age 38
2 children daughter age 18 and son age 14
Served/Veteran: no
If yes: Ever deployed? Yes or No
Living Arrangements: lives in a house with her husband and two
children

Code Status:
Full
Advanced Directives: yes
If no, do they want to fill them out? N/A
Surgery Date: 3/9/16 Procedure: tunnel catheter
placement under anesthesia

Culture/ Ethnicity /Nationality: White

Religion: Baptist

Type of Insurance: Humana - Cobra

1 CHIEF COMPLAINT:
I am not here for myasthenia gravis exacerbation like it says in the chart, I am here for a scheduled MG treatment that
was planned a month ago. I prefer to come into the hospital for the placement of the catheter because of my reaction to
medications they use in surgery. I am here for my monthly oil change.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay)
The patient presented to TGH for placement of a central line and to receive plasma exchange. She is currently receiving
these treatments monthly, and they are scheduled and planned. Toward the end of each month the patient notices a decline
in her health state with increasing weakness, easily becoming fatigued, experiencing intermittent ptosis, and difficulty
swallowing. Patient denies choking, but does have to take a sip of water between each bite of food while she is eating and
avoids foods that require a lot of chewing like steak. Patient endorses that she has dyspnea on exertion that has also been
worsening. The patient has been receiving a round of plasma exchange monthly for two months, and on previous
hospitalizations they have placed a non-tunneled catheter and removed it at the end of the ten day course of treatment.
They decided to put in a tunneled catheter this round in hopes that she could leave it in for three to four months and not
have to come to the hospital for each round of plasma exchange. The patient comes in for the placement of the catheter
each time because of the risk of having an adverse reaction to anesthesia. The patient and her team of doctors are going to
try the plasma exchange for three to four more months, and then reassess. If they feel that her condition has improved or
stabilized, they may attempt to switch back to intravenous immunoglobulin (IVIg) treatments. If the plasma exchange
does not help, they will consider switching to rituximab as a treatment. The patient was receiving two of the five PLEX
treatments while in the hospital, and would then complete the other three outpatient. She has already received one
exchange on 3/9/16, and would receive the second on 3/11/16. If tolerated well, the patient would be discharged on
3/11/16 with home health care for central line care and dressing changes.

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

Tumor

Stroke

Stomach Ulcers

Seizures

Problems
Mental Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

n/a

Diabetes

38

Cancer

Sister

Bleeds Easily

n/a

Asthma

65

Arthritis

Mother

Anemia

69

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
n/a

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Appendectomy
Cesarean section
Diagnosed with small fiber neuropathy via a non-definitive skin biopsy
Diagnosed with Myasthenia Gravis via single fiber electromyography

Age (in years)

Date
8th Grade
2001
2013
03/2014

relationship
relationship
relationship
relationship

Comments: Include age of onset

Father was diagnosed with prostate cancer at the age of 60.
Mother has Macular Degeneration and they are in the process of ruling out an MS diagnosis.

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
N/A
Adult Diphtheria had 2 years ago
Adult Tetanus had 3 years ago
Influenza (flu) allergy
Pneumococcal (pneumonia) allergy
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Influenza Vaccine
Versed
Fentanyl
Morphine
Lidocaine IV
DMSO

Medications

(Dimethylsulfoxide)

Tape

Type of Reaction (describe explicitly)

Anaphylaxis reaction occurred in 2011
Worsens her Myasthenia Gravis
Worsens her Myasthenia Gravis
Has a side effect (not allergic reaction) of severe vomiting and nausea
Worsens her Myasthenia Gravis
Anaphylaxis and hives
Rash/hives

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)

Myasthenia Gravis is an acquired autoimmune disease mediated by antibodies against the acetylcholine receptor at the
neuromuscular junction (Heuther &McCance, 2012). The post-synaptic acetylcholine receptors on the muscle cells
plasma membrane are no longer recognized as self and results in the generation of autoantibodies, IgG, which attach to
the receptor site and block the binding of acetylcholine (Heuther &McCance, 2012). According to the American Academy
of Opthamology (2013), there are no known risk factors for myasthenia gravis. The exact etiology of the disease is not
fully understood, but there is research suggesting that the thymus does play a role (Osborn, Wraa, Watson & Holleran,
2014). The patient usually presents with weakness in one muscle or one set of muscles that gets weaker with increased
muscle use, instead of just a generalized weakness (Osborn et al., 2014). The patient will go through fluctuating periods of
exacerbations and periods of remission (Osborn et al., 2014). Myasthenia gravis can affect any skeletal muscle groups
including ophthalmic muscles and oropharyngeal muscles (Osborn et al., 2014). There are several ways to diagnose MG,
which include giving the patient Tensilon to see if muscle strength improves, an electromyogram that measures the
electrical activity of a certain muscle, they can draw blood work to look for the acetylcholine receptor antibodies or
muscle specific kinase antibodies, and use an MRI to look for the presence of a thymoma (Heuther &McCance, 2012).
Treatment usually consists of a cholinesterase inhibitor like Mestinon, immunotherapy like the CellCept, and steroids
(Osborn et al., 2014). Patients may also participate in plasmapheresis to remove the AChR antibodies from circulation and
exchange for new plasma, or they may get intravenous immunoglobulin therapy (IVIg) which affects the antibody
production in the body (Osborn et al., 2014). With treatment, the patient could reach and stay in remission permanently,
but in some cases the disease can continue to progress and even lead to death (Heuther &McCance, 2012).

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

alpha lipoic acid

Route

oral

Concentration 600mg

Dosage Amount 600 mg

Frequency two times daily

Pharmaceutical class vitamin

Home

Hospital

or

Both

Indication nerve related symptoms in diabetes

Adverse/ Side effects hypoglycemia, mouth rash, can lower thiamine levels
Nursing considerations/ Patient Teaching signs and symptoms of hypoglycemia, avoid during pregnancy, avoid with alcohol, can interfere with thyroid treatments, do
not take if you are undergoing chemotherapy, may interact with some diabetic medications
Name enoxaparin (Lovenox)

Concentration 100 mg

Route subcutaneous

Dosage Amount 1 dose

Frequency every 12 hours

Pharmaceutical class antithrombotics/ low molecular weight heparin

Home

Hospital

or

Both

Indication prevention of venous thromboembolism; treatment of DVT with or without PE; prevention of ischemic complications from unstable angina and non-STsegment-elevation MI; treatment of acute ST-segment-elevation MI

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects dizziness, headache, insomnia, edema, constipation, increased liver enzymes, nausea, vomiting, urinary retention, alopecia, ecchymoses, pruritis,
rash, uticaria, hyperkalemia, bleeding, anemia, thrombocytopenia, irritation, erythema, pain, and hematoma at injection site, osteoporosis, fever
Nursing considerations/ Patient Teaching assess for signs of bleeding, assess for additional or increased thrombosis, monitor for hypersensitivity, assess anginal pain,
assess injection sites for hematomas, ecchymosis, or inflammation, monitor CBC, platelets, and stool for occult blood, may cause increase in AST/ALT levels, may cause
hyperkalemia, antidote is protamine sulfate (I mg for each mg of enoxaparin), alternate injection sites, administer deep in subcutaneous tissue, ice cube massage of site
may decrease bruising, do not expel air bubble from syringe before injection, patient should report any symptoms of unusual bleeding, bruising, dizziness, itching, rash,
fever, swelling, or difficulty breathing; instruct patient not to take aspirin, naproxen, or ibuprofen without consulting HCP
Do not confuse Lovenox with Levemir
Name pantoprazole (Protonix)
Route

Concentration 40 mg

oral

Pharmaceutical class proton pump inhibitor, anti-ulcer agent

Home

Dosage Amount 1 tablet

Frequency

daily

Hospital

or

Both

Indication erosive esophagitis, GERD, pathologic gastric hypersecretory conditions, off label: adjunctive treatment of duodenal ulcers associated with H. pylori
Adverse/ Side effects headache, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia, hypomagnesemia, bone fracture, and pseudomembranous colitis
Nursing considerations/ Patient Teaching assess for epigastric or abdominal pain; assess for occult blood in stool, emesis, or gastric aspirate; monitor liver function
tests; monitor serum magnesium; monitor bowel function; teach signs of pseudomembranous colitis; may take with or without food; do not break, crush, or chew tablets;
take as directed for full course of therapy; avoid alcohol, aspirin and NSAIDS; report changes in stool; notify HCP of side effects or plans for pregnancy
Do not confuse Protonix with Lotronex or protamine.
Name mycophenolate (CellCept)

Concentration 750 mg

Route oral

Dosage Amount 1 capsule

Frequency two times daily

Pharmaceutical class immunosuppressants

Home

Hospital

or

Both

Indication kidney, heart, and liver transplant anti-rejection medication

Adverse/ Side effects progressive multifocal leukoencephalopathy, anxiety, dizziness, headache, insomnia, paresthesia, tremor, edema, hypertension, hypotension,
tachycardia, rashes, hypercholesterolemia, hyperglycemia, hyperkalemia, hypocalcemia, hypokalemia, hypomagnesemia, GI bleeding, anorexia, constipation, diarrhea,
nausea, vomiting, abdominal pain, renal dysfunction, leukocytosis, leukopenia, thrombocytopenia, anemia, pure red cell aplasia, cough, dyspnea, fever, infection, and
increased risk of malignancy
Nursing considerations/ Patient Teaching do not crush/chew capsule, assess for s/s of organ rejection, asses for progressive multifocal leukoencephalopathy
(hemiparesis, apathy, confusion, cognitive deficiencies, and ataxia), do routine pregnancy tests during therapy, monitor CBC, monitor renal and hepatic status, monitor
electrolytes, take on an empty stomach (1 hour before or 2 hours after eating), do not take with antacids that contain magnesium or aluminum, take as directed, reinforce
the need for life long therapy, avoid people with contagious diseases, avoid vaccines with a live virus, , wear sunscreen and protective clothing to decrease risk of skin
cancer, use two forms of contraception, complete all routine follow up blood work and appointments, inform HCP of any side effects
Name prednisone (Deltasone)
Route

Concentration 10 mg

oral

Dosage Amount 1 tablet

Frequency daily

Pharmaceutical class steroidal anti-inflammatory

Home

Hospital

or

Both

Indication chronic inflammatory, allergic, hematologic, neoplastic, and autoimmune disorders

Adverse/ Side effects depression, euphoria, headache, increased intracranial pressure, personality changes, psychoses, restlessness, cataracts, increased intraocular
pressure, hypertension, peptic ulceration, anorexia, nausea, vomiting, acne, decreased wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression,
hyperglycemia, fluid retention, hypokalemia, hypokalemic alkalosis, thromboembolism, thrombophlebitis, weight gain/loss, muscle wasting, osteoporosis, avascular
necrosis of joints, muscle pain, cushingnoid appearance, increases susceptibility to infection
Nursing considerations/ Patient Teaching assess for signs of adrenal insufficiency, monitor intake and output, observe for peripheral edema, weight gain, creakles, or
dyspnea, monitor electrolytes and glucose, administer in the morning when the body naturally releases cortisol, take with meals to decrease GI symptoms, do not suddenly
stop taking the medication, avoid vaccines without consulting with HCP, inform HCP of any side effects, discuss potential changes in physical appearance, complete all
follow appointments and lab work, eat a diet high in protein, calcium, and potassium and a diet low in sodium and carbohydrates, avoid alcohol
Name pregabalin (Lyrica)

Concentration 150 mg

Route oral

Dosage Amount 1 capsule

Frequency two times daily

Pharmaceutical class gamma aminobutyric acid gaba analogues,

Home
Hospital
or
Both
nonopiod analgesic
Indication neuropathic pain, postherpetic neuralgia, fibromyalgia, neuropathic pain associated with spinal cord injury, adjunctive therapy for partial-onset seizures in
adults
Adverse/ Side effects suicidal thoughts, dizziness, drowsiness, impaired attention/concentration/thinking, edema, blurred vision, dry mouth, abdominal pain, constipation,
increased appetite, vomiting, thrombocytopenia, weight gain, allergic reactions, fever
Nursing considerations/ Patient Teaching monitor closely for changes in behavior, assess characteristics of pain throughout therapy, assess for seizure activity, may
cause increase in creatine kinase levels, monitor platelet levels, do not abruptly stop taking the medication, can take with or without meals, take medication as directed,
use caution with driving until side effects are known, report muscular changes to HCP, notify HCP immediately if you have any thoughts of suicide, advise patient that
weight gain and edema are known side effects, avoid alcohol and other CNS depressants, notify HCP if planning a pregnancy
Name potassium chloride SA (K-Dur)

Concentration 20 mEq

Route Oral

Dosage Amount 1 tablet for K+ 3.5-3.9 or

2 tablets for K+ <3.5 mg/dl
Frequency PRN

Pharmaceutical class mineral and electrolyte replacements/supplements

Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication treatment/prevention of potassium depletion

Adverse/ Side effects confusion, restlessness, weakness, arrhythmias, ECG changes, abdominal pain, flatulence, nausea, vomiting, GI ulceration, stenotic lesions,
paralysis, paresthesia
Nursing considerations/ Patient Teaching assess for s/s of hypokalemia and hyperkalemia; monitor serum potassium, renal function, serum bicarbonate, pH, serum
chloride and serum magnesium levels (if hypomagnesemia is present you will have to replace magnesium first); monitor for symptoms of toxicity (hyperkalemia);
administer with or after meals and with a full glass of water to decrease gastric irritation; explain the purpose of the medication to the patient; missed doses can be taken if
remembered within 2 hours of scheduled time; take as directed; avoid salt substitutes or low-salt milk or food; teach good sources of dietary potassium and the importance
of compliance with recommended diet; report any dark, tarry or bloody stools, weakness, unusual fatigue, tingling of extremeties or other side effects; importance of
regular follow up exams to monitor serum potassium levels and progress
Name pyridostigmine (Mestinon)

Concentration 60 mg

Route oral

Dosage Amount 1 tablet

Frequency 5 times daily

Pharmaceutical class antimyasthenic, cholinergics

Home

Hospital

or

Both

Indication increase muscle strength in symptomatic treatment of myasthenia gravis, reversal of nondepolarizing neuromuscular blocking agents, prophylaxis of lethal
effects of poisoning with the nerve agent soman
Adverse/ Side effects seizures, dizziness, weakness, lacrimation, miosis, bronchospasm, excessive secretions, bradycardia, hypotension, abdominal cramps diarrhea,
excessive salivation, nausea, vomiting, sweating, rashes
Nursing considerations/ Patient Teaching assess VS for changes, assess neuromuscular status, atropine is antidote, administer with food or milk to minimize side
effects, take as directed, do not skip or double up doses, space out activities to avoid fatigue, carry identification of medications and medical conditions
Name Topiramate ER (Trokendi ER)

Concentration 150 mg

Route PO
Pharmaceutical class

Dosage Amount 2 capsules

Frequency daily

anticonvulsants, mood stabilzers

Home

Hospital

or

Both

Indication seizures, preventions of migraines

Adverse/ Side effects increase serizures, suicidal thoughts, dizziness, drowsiness, fatigue, impaired concentration/memory, nervousness, psychomotor slowing, speech
problems, sedation, aggressive reaction, agitation, anxiety, cognitive disorders, confusion, depression, malaise, mood problems, abnormal vision, diplopia, nystagmus,
acute myopia/secondary angle closure glaucoma, nausea, abdominal pain, anorexia, constipation, dry mouth, encephalopathy, hyperammonemia, kidney stones,
oligohydrosis, hyperchloremic metabolic acidosis, leukopenia, weight loss, hyperthermia, ataxia, paresthesia, tremor, fever
Nursing considerations/ Patient Teaching monitor for changes in behavior, assess for seizure activity, assess migraines, assess mental status, monitor CBC with
differential, monitor hepatic function, monitor serum bicarbonate, implement seizure precautions, can take with or without food, take as directed, may cause decreased
sweating and increase body temperature, use caution while driving until side effects are known, maintain fluid intake of 2000-3000 mL, notify HCP of periorbital pain or
blurred vision, immediately notify HCP of suicidal thoughts, teach s/s of encephalopathy, change positions slowly, avoid alcohol and CNS depressants, use sunscreen and
protective clothing, use a non-hormonal contraceptive, carry medication and medical diagnosis identification
Name acetaminophen (Tylenol)

Concentration 325 mg/tablet

Route PO
Pharmaceutical class

Dosage Amount 2 tablets

Frequency every 6 hours PRN for pain

antipyretics, nonopioid analgesics

Home

Hospital

or

Both

Indication treatment of mild pain and fever

Adverse/ Side effects agitation, anxiety, headache, fatigue, insomnia, atelectasis, dyspnea, hypertension, hypotension, hepatotoxicity, constipation, increased liver
enzymes, nausea, vomiting, hypokalemia, renal failure, neutropenia, pancytopenia, muscle spasms, trismus, acute generalized exanthematous pustulosis, stevens-johnson
syndrome, toxic epidermal necrolysis, rash, uticaria
Nursing considerations/ Patient Teaching assess overall health status and alcohol usage, monitor medications that the patient is taking, monitor for a rash during
therapy, assess pain, assess fever, monitor hepatic, hematologic and renal function, acetylcysteine is antidote for overdose, double check dosing, monitor for Tylenol in
other pain medication preparations, take with a full glass of water, take with or without food, take medication as directed, do not exceed recommended daily amount,
avoid alcohol, stop use if rash occurs, closely monitor blood glucose, check medication labels, check concentrations,

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?
Regular
Analysis of Home Diet (Compare to My Plate and Consider co-morbidities and
cultural considerations):
Diet patient follows at home? Regular
24 HR average home diet:
The patient is consuming an average of 1184 calories per day of the
Breakfast: 1 piece of bacon, 1 cup of grapes, 1
recommended 2000 calorie regular diet. The patient has reached
scrambled egg
the goals for protein and vegetables. She actually consumed 8oz. of
protein with the recommendation being 5 oz. She also consumed
more vegetables than is recommended for each day, so she could
Lunch: a can of soup, 1 cutie orange
exchange her vegetable snack for a fruit to equal those levels out a
little more. The patient is not meeting the daily recommendation for
grains and the grains she is consuming are refined instead of whole
Dinner: 1 serving of spaghetti, side salad with lite
grains. She could add grains to her diet by consuming oatmeal,
Italian dressing
making a sandwich using whole grain bread, or using wild rice in
her chicken soup instead of noodles. The patient is not consuming
enough dairy in her diet, and would benefit from adding a cup of
Snacks: 1 cup of carrots, 1 mozzeralla cheese stick yogurt as a snack to help level out the vegetables and the dairy
options. She has limited the amount of added sugars she is taking
in, but she is consuming almost 4,000 mg of sodium with the
Liquids (include alcohol): 2 cups of coffee, 1 cup
recommended daily amount being 2300 mg. Making sure to not add
of tea, 6 glasses of water
salt to her cooking preparations and choosing low sodium soups
and bacon will help to lower this amount.
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.

ChooseMyPlate (2016, April 6)

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My husband, kids, and my parents if needed.
How do you generally cope with stress? or What do you do when you are upset?
I cry to my hubby, and rely on my faith.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I am at peace with the Lord. I feel overwhelmed at times being in limbo, and wanting to go back to work. My social life
is difficult because it is difficult to get with my friends when I get so fatigued by the end of the day.
+2 DOMESTIC VIOLENCE ASSESSMENT
Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? No Have you ever been hit punched or slapped? No
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No
If yes, have you sought help for this? N/A
Are you currently in a safe relationship? Yes, we were high school sweethearts.

University of South Florida College of Nursing Revision September 2014

 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:

Treas and Wilkinson (2014) define intimacy as the ability to commit to others in relationships and stick to
those commitments, and they define isolation as an avoidance of intimacy. The goal in this stage is to develop
relationships and commit to a job.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the intimacy vs. isolation stage. I feel like this patient is nearing the end of this stage, but with the decline
in her health, it has made some changes to her life. She is in a stable and monogamous relationship with her husband of
twenty-two plus years. She has a good relationship with her kids, and expressed having good friendships as well. Her
friendships have changed a little with her increased fatigue and not being able to socialize as much as she used to. She had
a job working as a pediatric nurse, and really loved what she did. She desires to go back to work, but is not sure that she
will be able to. She has succeeded with intimacy, but it has changed slightly. I believe that as she continues to accept the
limitations of her condition, she will move into generativity sooner rather than later.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I think that it has kind of kept her in the isolation vs. intimacy category as she learns her limitations and adjusts her
relationships and career to fit into those newer and continuously changing limitations. She has relationships, but I also
think that she is desiring to form new relationships with people who understand exactly what she is going through each
day with her myasthenia gravis.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I think that an anaphylactic reaction to the flu vaccine turned on an immune response that resulted in Myasthenia Gravis
and the small fiber neuropathy.
What does your illness mean to you?
It is a growing experience. I have learned to go day by day. It has created closer family relationships with my husband
and my kids especially.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Men
Are you aware of ever having a sexually transmitted infection? No
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? I had a tubal ligation when I had my c-section.
How long have you been with your current partner? 22+ years
Have any medical or surgical conditions changed your ability to have sexual activity? Affects of myasthenia gravis
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
Patient stated, A lot.
Do your religious beliefs influence your current condition?
Yes, it has given me coping skills.

+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? N/A
How much? (specify daily amount)
N/A

Yes
No
For how many years? N/A
(age

thru

If applicable, when did the

patient quit? N/A

Pack Years: N/A

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

Has the patient ever tried to quit? N/A

If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? N/A
How much? N/A
Volume: N/A
Frequency: N/A
If applicable, when did the patient quit?
Not applicable

Yes

No
For how many years? N/A

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
She was exposed to chemotherapy on the hematology-oncology floor she worked on for 18 years.
5. For Veterans: Have you had any kind of service related exposure?
Not applicable

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes reactions to medication
Skin infections

Nausea, vomiting, or diarrhea

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

Use of sunscreen

Diverticulitis

Integumentary

SPF: 30-50

Immunologic
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction (flu
vaccine, DMSO, & a bagel)

Appendicitis 8th grade

Abdominal Abscess
Last colonoscopy?
Other:

Enlarged lymph nodes

Other:

Difficulty seeing wears glasses

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
2+ x/day
Routine dentist visits
2 x/year
Vision screening 2 x/yr
Other: blepharitis

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: OOther:

Pulmonary

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam 1x/yr
Date of last gyn exam? August 2015
menstrual cycle
regular
menarche
age? 12
menopause
age?
Date of last Mammogram &Result: 1 yr.
ago cystic breast
Date of DEXA Bone Density & Result: n/a

Bathing routine: daily

Other:

HEENT

Difficulty Breathing (Chronically SOB)

Cough
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? About 2 years ago
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain/Angina (currently but no PMH)
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus (likely origin of the PE)
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 1 yr. ago
Other: Hypotension

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 10 x/day
Bladder or kidney infections occasionally
Pt. drinks a lot of water which contributes
to amount of time she using bathroom
each day

MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot AND cold
Osteoporosis
Other:

Central Nervous System

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures Left foot fracture
Weakness in legs and arms
Pain back & neck improved w/ rest
Gout
Osteomyelitis
Arthritis
Other: Myasthenia Gravis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision September 2014

General Constitution
Recent weight loss or gain - recent weight loss when they started to lower her prednisone dose
How many lbs? about 20 pounds
Time frame? weeks
Intentional? yes
How do you view your overall health? not the greatest

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
The patient did not verbalize anything.
Any other questions or comments that your patient would like you to know?
No, I dont think so

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10 PHYSICAL EXAMINATION:
General Survey: Pt. is a
Height 5 ft. 4 in.
Weight 158 lbs.
BMI 26.35
Pain: (include rating and location)
42 y.o. slightly
0 out of 10 currently
Pulse 60
Blood Pressure: (include location)
overweight female who
102/51 Left Arm
Respirations 16
is alert and oriented x4
with no visible signs of
distress.
Temperature: 98.6 Oral
SpO2 99%
Patient was on room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other: Patient was willing to teach and explain her condition.
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
Peripheral IV site Type: 22 gauge
Location: right hand
Date inserted: 03/09/16
no redness, edema, or discharge
Fluids infusing?
no
yes - what?

flat
loud

Central access device Type: Perm Cath Location: Right IJ

Date inserted: 03/09/16
no redness, edema, or discharge pt. stated she was very sensitive to the clear dressing over it
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 18 inches & left ear- 18 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: white, intact, clean & free of food, no dentures or dental caries
Comments: Thyroid was not palpated because there was no indication for it to be palpated and I did not feel comfortable
since we did not get to ever really practice this assessment.
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
N/A
Color: white pale yellow yellow dark yellow green gray light tan brown red
N/A
Lung sounds: CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent
RUL CL
LUL CL
RML CL
LLL CL
RLL CL
Comments:

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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)
Patient was not on telemetry, and she did not have an ECG 12 lead this hospital visit.

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: not assessed Popliteal: not assessed 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
Comments:
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 03 / 10 / 16 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
GU
Urine output:
Clear
Cloudy
Color: Yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness not assessed

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output: N/A not being measured
without assistance

or

with assistance

Musculoskeletal:
Full ROM intact in all extremities without crepitus
Strength bilaterally equal at 4 RUE 4 LUE 3 RLE & 3 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

Comments: DTR were not assessed, we have never practiced them in lab and there was no reflex hammer available.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
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12

abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Urinalysis Urine had specific gravity of 1.003, which is below the normal range of 1.007-1.030, the pH was a
5.0, and it was negative for any kinds of bacteria.
The patient was not getting daily lab work, and there was only one set of blood values. I was able to pull the
results from her previous hospitalization, to see if her blood work was changing.
Lab
Dates
Trend
Analysis
WBC
The WBC level was
5.91
2/13/16
within normal range.
8.66
Normal (4.6-10.2)
Hemoglobin
13.8 L
13.4 L

3/8/16

2/13/16
3/8/16

Hemoglobin was
consistently below
normal range, but just
outside of normal limits.

Normal (14.0-18.1 g/dL)

Hematocrit
43.0 L

2/13/16

40.1 L

3/8/16

Hematocrit was
consistently below
normal range, but just
outside the normal limits.

192

2/13/16

Platelets are within the

normal range.

218

3/8/16

Normal (43.5%-53.7%)
Platelets

Normal (142-424)
Sodium
140
140

2/13/16

Sodium was within

normal range.

3/8/16

Normal (135-148 mEq/dL)

Potassium
3.4 L

2/13/16

3.8

3/8/16

Normal (3.5-5.3 mEq/dL)

Chloride
111 H

These are not alarming

hemoglobin levels, but it
could be a result of the
Cellcept
immunosuppressant she is
taking, as one of the side
effects is anemia.
These are not alarming
hematocrit levels, but it
could be a result of the
Cellcept
immunosuppressant she is
taking, as one of the side
effects is anemia.

Potassium was currently

within normal range, but
on the lower end of
normal.
Chloride was higher than
the normal limits, but the
values are just outside of
normal.

The patients chloride was

2/13/16
high and based on my
research of the diagnoses
3/8/16
112 H
there is not a direct
correlation. She was well
University of South Florida College of Nursing Revision September 2014
13

Normal (98-107 mEq/dL)

Carbon Dioxide
22

2/13/16

20 L

3/8/16

CO2 was within the

normal range, but
currently just below the
normal limits.

13

2/13/16

BUN was within normal

range.

12

3/8/16

Normal (22-29 mEq/dL)

BUN

Normal (6.0-20 mg/dL)

Creatinine
0.8
0.9

2/13/16

Creatinine was within the

normal range.

3/8/16

Normal (0.72-1.25 mg/dL)

Glucose
91

2/13/16

106

3/8/16

Normal (70-110 mg/dL)

Albumin
4.2

Glucose was within the

normal range.

3/8/16

Albumin was within the

normal range.

3/9/16

PTT was within the

normal range.

Normal (25.1-36.5)
Protime
11.9

3/9/16

Protime is within the

normal range.

Normal (9.4-12.5)
INR
1.1

3/9/16

Normal (0.8-1.2)
Fibrinogen
220

3/9/16

Normal (3.5-5.0 g/dL)

PTT
29.0

hydrated, and only

experiencing difficulty
breathing on exertion.
The patients CO2 was
high and based on my
research of the diagnoses
there is not a direct
correlation. She was well
hydrated, and only
experiencing difficulty
breathing on exertion.

INR is within normal

limits for a patient not on
Warfarin therapy.
Fibrinogen was within the
normal range one month
ago, but is now below
normal limits.

This level was checked

because albumin was
used as a replacement
112 L
3/10/16
fluid during plasma
exchange.
University of South Florida College of Nursing Revision September 2014
14

Normal (190-500 mg/dL)

Hypofibrinogenemia is
common in plasma
exchange with the use of
albumin.

Magnesium
2.4

3/9/16

Magnesium level was

within the normal limits.

Normal (1.5-2.5 mEq/L)

+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.)

The patients treatment team included nephrology for plasma exchange orders, respiratory for forced vital capacity, and
speech language therapy for a swallow study.
The patient was receiving vital sign checks every four hours, was up independently ad lib, and was on a regular diet.
The swallow study did find that there was residue left over and not going down all the way, and the recommendation was
small meals more frequently, consuming meals with liquids, and maybe even a mechanical soft diet to prevent fatigue
while eating.
The patient went to interventional radiology on 3/9/16, for the placement of tunneled hemodialysis catheter, it was placed
successfully in the right internal jugular vein under ultrasound guidance.
The patient has a consult with case management as they were working out the details of getting central line care at home.
If they could not find someone to commit to the central line dressing changes, then the patient would not be allowed to
leave it in for the three to four months.
The patient had received and would be receiving one more peritoneal dialysis with plasma exchange before discharge.

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

1. Risk for aspiration related to impaired swallowing and chewing fatigue.
2. Risk for infection related to central line placement.
3. Risk for falls related to impaired physical mobility.
4. Impaired swallowing related to neuromuscular impairment as evidenced by residual left during swallow study.
5. Impaired physical mobility related to decreased muscle strength as evidenced by exertional dyspnea and slowed
movement.
6. Activity intolerance related to increasing weakness as evidenced by exertional dyspnea and verbal report of weakness
and fatigue.
7. Imbalanced Nutrition: less than body requirements related to impaired swallowing and chewing fatigue as
evidenced by poor muscle tone and residual left during swallow study.
8. Fatigue related to aching muscles as evidenced by lack of energy and increase in rest requirements.
9. Social isolation related to altered state of wellness as evidenced by expression of loneliness and feeling misunderstood.
10. Sexual dysfunction related to altered body function as evidenced by actual and perceived limitation imposed by disease.

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15

 15 CARE PLAN
Nursing Diagnosis: Impaired physical mobility related to decreased muscle strength as evidenced by exertional dyspnea and slowed movement
(Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
The patient will display increased
*1. Evaluate motor strength before 1. The abilities of the patient
This goal was met. The patient did
physical activity to 300 steps per
and after activity.
should be assessed to determine
walk in her room to and from the
days while in the hospital.
how to best facilitate movement
bathroom throughout the day. The
(Ackley & Ladwig, 2011).
patient also took a walk about
2.
Using
a
pedometer
will
allow
the
Short term goal #1
*2. Use a pedometer to calculate
halfway down the unit floor two
steps taken and activity performed. patient to keep track of steps taken, times during my shift. The patient
and know how many more steps to needs to continue to add more and
take to reach their daily goal.
more steps each day, to make sure
*3. Teach patient to go from lying
3. Postural hypotension and
she is utilizing her muscles without
down to standing up slowly to
dizziness is a side effect of many of depleting herself of all her energy.
avoid orthostatic hypotension,
the medications she is on.
progressive mobilization.
4. Assistive devices help to
*4. Obtain assistive device needed increase mobility and confidence
(Ackley & Ladwig, 2011).
for activity and independence.
The patient will perform range of
*1. Assess for and treat pain and
1. Pain limits mobility and and is
This goal was partially met. The
motion exercises for joint mobility weakness before and after exercise. often exacerbated by movement
patient did perform some range of
(Ackley & Ladwig, 2011).
during times of limited movement.
motion exercises with her legs and
*2. Perform active range of motion 2. These exercises help to reverse
elbows. The exercises were very
weakening
and
atrophy
of
muscles
Short term goal #2
exercises per patient tolerance.
limited but she did demonstrate that
(Ackley & Ladwig, 2011).
she has knowledge to continue to
3.
Fear
of
breathlessness,
pain
or
3. Provide emotional support and
apply these movements at home.
falling may decrease willingness to
encouragement to the client to
increase activity (Ackley & Ladwig,
gradually increase activity and set
2011).
mutual goals.
The patient will find an exercise
* 1. Patient will start an exercise
1. Clients should be encouraged to This goal was not met. We did
regimen that works to increase
log to record types of exercise
use exercise logs or diaries to
discuss different kinds of exercise
muscle strength without depleting
completed, muscles targeted, and to improve adherence to the mobility that she could try at home, but this
all energy.
rate muscle strength before and
enhancement prescription (Ackley & goal requires trial and error when
Ladwig, 2011).
after each activity.
the patient goes home. The patient
2. Assistive devices help to
*2. Assess patient for the need of
did express that she does not want a
increase mobility and confidence
Long term goal #1
desire to use an assistive device to
walker, but that she does feel like
University of South Florida College of Nursing Revision September 2014

16

help increase the amount of activity (Ackley & Ladwig, 2011).

they can complete.

she is getting close to the point

where she might require it when
there is no one else home for extra
security when she becomes
fatigued.

Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to impaired swallowing and chewing fatigue as evidenced by poor
muscle tone and residual left during swallow study (Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will maintain diet that
*1. Compare usual food intake
1. Omission of entire food groups
This goal was partially met. We did
meets daily caloric goals and
with the Food Guide Pyramid,
increases risks of deficiencies
discuss a typically daily diet and
(Ackley
&
Ladwig,
2011).
needs.
noting slighted or omitted food
that she is less fatigued in the
groups. Teach patient how to use
morning and that is when she
Short and long term goal #1
Supertracker on Choose My Plate
should consume a larger portion of
website.
her calories. I told the patient about
2. Determine time of day when
the website we use to compare
2. Client is often less fatigued in
clients muscles and appetite are
what we are consuming to what we
the morning so a good hearty
best and plan for greatest caloric
should be consuming, so maybe
breakfast may be the best option.
intake at that time.
she will go home and take a look.
Patient will demonstrate techniques *1. Eat meals sitting upright at a 90 1. Sitting upright aids the body in
This goal was partially met. The
to aid in the swallowing of food to degree angle.
moving the food down the
speech-language therapist did come
prevent aspiration and chewing
esophagus.
in and complete a swallow study
fatigue.
*2. Allow time to chew and
2. This will lower the patients
with the patient and found that she
swallow before taking another bite. chances of choking.
did have residue left. They
Short and long term goal #2
discussed the importance or a softer
*3. Prepare foods in a way that
3. Choosing foods that are soft,
diet, cutting things up into small
make them softer and easier to
easy to breakdown, or cooking
easy to chew bites, and eating
chew.
foods to make them soft will
slowly. The patient did demonstrate
decrease the likelihood of getting
good posture while eating lunch.
chewing fatigue.
Patient will maintain weight
*1. Patient will keep a diary of
1. Use of a food diary is helpful for This goal was not met. The patient
appropriate for height and age.
food intake and monitory weekly
both patient and clinician to exam
has seen a quick reduction in
weights.
eating patterns and the presence of weight loss due to a change in
Short and long term goal #3
deficiencies (Ackley & Ladwig, 2011). medications, but the patient is not
*2. Encourage patient to develop a 2. Increasing the desire to eat will
underweight. Once the patient
University of South Florida College of Nursing Revision September 2014

17

plan for light exercise to increase

appetite without burning too many
calories.
3. Eat meals with friends and/or
families.

help improve the caloric intake for

each day to help maintain optimal
weight.
3. Mealtime usually is a time for
social interaction; often clients eat
more food if other people are
present at mealtimes (Ackley &

reaches normal BMI, she will have

to consume more calories each day
(than she does currently) to
maintain a healthy weight.

Ladwig, 2011).

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
X SS Consult for assistance in finding home health care that is certified to properly complete dressing changes and cleaning of Tunneled catheter
X Dietary Consult to develop a diet that meets caloric needs and protects the client from chewing fatigue and aspiration
X PT/ OT
Pastoral Care
Durable Medical Needs patient mentioned that she may need to get a walker to use at home, when no one is home to assist her
X F/U appointments 3 more plasma exchanges over the course of the next 8 days.
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
X Rehab/ HH HH for dressing changes and maintenance of tunneled Perm Cath
Palliative Care
The patient would need discharge review of her medications and potential side effects, but there was no new medications started on this admission.
The patient would also need teaching on the maintenance and care of her tunneled central catheter, to minimize the risk of infection. It would be
important to teach on the signs and symptoms of infection, so the patient and the family know what they are looking for. This patient was very
knowledgeable on her disease and limitations, so she would really just need a review of the information and answers to any questions she had. The
biggest concern for discharge was finding someone who was able to maintain the central line for her, or getting the supplies she needs to do the
changes herself with the help of a nurse friend because they are both certified to care for the tunneled central access lines.

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18

References
Ackley, J. B., & Ladwig, B. G. (2011). Nursing diagnosis handbook: An evidenced-based guide to planning
care (10th ed.). Maryland Heights, MI: Elsevier.
American Association of Opthamology. (2013). Myasthenia Gravis: Causes, Symptoms, and Risk. Retrieved
from: http://www.aao.org/eye-health/diseases/myasthenia-gravis-causes-symptoms-risk
ChooseMyPlate (2016, April 6). Super tracker [Online nutrition tool]. Retrieved from
http://www.choosemyplate.gov/tools-supertracker.
Huether, S. E., & McCance, K. L. (2012). Alterations in Pulmonary Function: Pulmonary Embolism. (5th ed.).
Understanding pathophysiology (pp. 698-699). St. Louis, MO: Elsevier.
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical Surgical Nursing Preparation for
Practice (2nd ed.). Boston, MA: Pearson Education, Inc.
Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia, PA: F.A.
Davis Company.
Unbound Medicine (2015). Nursing central: Davis drug guide (Version 1.27)[Mobile application software].
Retrieved from: USF Computer Store.

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