UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Haley Higgins
Assignment Date: 9/30/2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: St. Josephs Hospital
1 PATIENT INFORMATION
Patient Initials: S.L.M. Age: 58 Admission Date: 9/29/2016
Gender: Female Marital Status: Married Primary Medical Diagnosis: lumbar spinal
stenosis
Primary Language: English
Level of Education: College, Bachelors Degree Other Medical Diagnoses (new on this
admission): none
Occupation (if retired, what from?): Real estate agent
Number/ages children/siblings: no children (gravida 0 para 0)
1 brother age 61
1 sister age 57
Served/Veteran: No Code Status: Full code
If yes: Ever deployed? NA
Living Arrangements: Lives at home with wife Advanced Directives: Yes
If no, do they want to fill them out? N/A
Surgery Date: 9/29/2016 Procedure: transforaminal lumbar interbody
fusion with internal fixation at L4-L5 and wide
decompressive lumbar laminectomy at L2 through
S1
Culture/ Ethnicity /Nationality: White
Religion: Christian Type of Insurance: United Healthcare

1 CHIEF COMPLAINT: Over the last few years I developed back problems. I have always been very
physically active, but my back began giving me problems about 3 years ago. Over the last year, it has gotten
worse to where my feet are constantly numb and I get a tingling sensation in my legs. I decided to go ahead
with surgery to fix my spine so that it doesnt get any worse. Once the numbness began, my biggest fear was
becoming paralyzed so I knew I had to finally have surgery.
3 HISTORY OF PRESENT ILLNESS: Patient was admitted to the hospital on 9/29/2016 for a scheduled
spinal surgery to be performed that day. Previous MRI revealed lumbar spinal stenosis and surgery was
determined to be the best treatment option. A transforaminal lumbar interbody fusion with internal fixation at
L4-L5 and wide decompressive lumbar laminectomy at L2 through S1 were performed. Patient states that prior
to the surgery pain varied depending on the day, but was generally an 8 out of 10. Patient states pain would
come and go, but was more severe when standing or walking for long periods of time. Patient would describe
pain as throbbing. Pain was located in lower back and would radiate down the buttocks and both legs. Pain was
relieved by resting and elevating legs. Currently, patient rates pain at a 4 out of 10. Pain occurs gradually and is
located in the lower back. Once the pain begins, it is constant and throbbing. Pain is aggravated by movement.
Pain is relieved by pain medication, rest, and placing pillows behind back so that she is not lying flat on back.
Patient has experienced numbness in both feet prior to and after the surgery. Numbness began about 6 months
ago.
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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: Include hospitalizations for any medical
illness or operation; include treatment/management of disease.
Date Operation or Illness
10/1998 Uterine fibroids, Hysterectomy
2005 Diagnosed with hypertension, stopped smoking cigarettes and started taking Lisinopril to manage
2007 Menopause, treating symptoms with Premarin 2.5 mg
2010 Colon polyps, Colonoscopy with polypectomy
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
Cause

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
of

Mental
Heart
HISTORY Death

(angina,
(if
applicable)
Father 78 Lung cancer
Mother 71 Lymphoma
Brother 61 NA
Sister 57 NA
Comments: Patients father died at the age of 78 due to metastatic lung cancer. Father also had arthritis and hypertension. Patients
mother died at the age of 71 due to complications from lymphoma treatment (believes she developed an infection that led to her death).
Mother also had hypertension. Patients brother is 61 years old, medical issues are environmental allergies and hypertension. Patients
brother also had a CABG X 4 and valve surgery in his 50s. Patients sister is 57 years old, only medical issues are environmental
allergies and chronic migraines. Patient does not have any children.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria 2010
Adult Tetanus 2010
Influenza (flu) Patient does not want flu shot
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or occupational
purposes? Typhoid, 2010

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Medications Penicillin Skin rash/hives
No known food
allergies. No known
Other (food, tape, environmental
latex, dye, etc.) allergies. No known
allergy to latex, tape,
or dye.

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 5 PATHOPHYSIOLOGY:
Spinal stenosis is defined as any abnormal narrowing of the spinal canal. In spinal stenosis, the narrowing of the
canal places pressure on the nerves and spinal cord which can result in various neurological symptoms. Spinal
stenosis is most commonly seen in men and women over the age of 50 and occurs as a result of degeneration of
the spinal column due to natural aging. Osteoarthritis, rheumatoid arthritis, tumors of the spine and traumatic
injuries are also common causes of spinal stenosis. In patients under the age of 50, the main causes of spinal
stenosis are traumatic injury and congenital defects (National Institute of Arthritis and Musculoskeletal and Skin
Diseases, 2013).
Spinal stenosis most often occurs in the cervical and lumbar portions of the spine. Common symptoms of spinal
stenosis include neck and back pain, numbness or weakness in the arms or legs, and pain that radiates down the
legs. Bladder and bowel function can also be impaired if the nerves controlling these functions are compressed
or damaged due to the stenosis. Neurogenic claudication is a common sign of lumbar spinal stenosis and is
characterized by leg pain with walking (Parizel, Van Hoyweghen, Bali, Van Goethem, & Van Den Hauwe,
2016).
To diagnose spinal stenosis, a complete medical history must be obtained and a physical exam is performed.
Then, imaging studies are performed to determine the location and severity of the issue. The most common
imaging techniques used are MRI, CT, X ray, myelogram and bone scans.
After the diagnosis has been made, the severity of the stenosis is determined so that a proper treatment program
can be developed. If it is determined that the stenosis is not causing severe nerve damage, nonsurgical
treatments are used. These nonsurgical treatments may include the use of analgesics, corticosteroids and non-
steroidal inflammatory drugs to reduce inflammation and treat pain. Patients may also be prescribed physical
therapy to maintain full range of motion and strength of the spine. IN some cases, surgery is required to relieve
the compression on the spinal cord and/or nerves. Chiropractic treatments and acupuncture are common
alternative treatments used to reduce pain and pressure on the spine (National Institute of Arthritis and
Musculoskeletal and Skin Diseases, 2013).

5 MEDICATIONS:
Name conjugated estrogens (Premarin) Concentration 1.25 mg Dosage Amount 1 tablet
Route PO Frequency 1 X daily
Pharmaceutical class hormone Home Hospital or Both
Indication symptoms of menopause, prevention of post-menopausal osteoporosis
Adverse/ Side effects headache, edema, hypertension, nausea, weight changes, amenorrhea, breast tenderness, skin pigmentation
changes
Nursing considerations/ Patient Teaching avoid grapefruit juice, do not stop taking suddenly (may cause withdrawal bleeding), report
any signs of fluid retention to nurse/provider (swelling of feet and ankles, weight gain), use sunscreen when outdoors

Name lisinopril (Prinivil) Concentration 2.5 mg Dosage Amount 1 tablet

Route PO Frequency 2 X daily
Pharmaceutical class Angiotensin-converting enzyme
Home Hospital or Both
(ACE) inhibitors
Indication hypertension
Adverse/ Side effects cough, hypotension, taste disturbances, angioedema
Nursing considerations/ Patient Teaching monitor blood pressure and pulses before administration, monitor for fluid overload,
instruct patients to take as directed every day, do not double dose if a dose is missed, avoid salt substitutes or foods high in potassium,
may cause dizziness, change positions slowly

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Name morphine (Astramorph, Duramorph) Concentration 1 mg/mL Dosage Amount 2 mg
Route PCA Frequency every 7 minutes, with a 1 hour limit of 8 doses
Pharmaceutical class opioid analgesic Home Hospital or Both
Indication as needed for pain
Adverse/ Side effects confusion, sedation, respiratory depression, hypotension, constipation, nausea, vomiting
Nursing considerations/ Patient Teaching only patient may push PCA button to avoid respiratory depression; assess location/intensity
of pain frequently; assess level of consciousness, blood pressure and respirations frequently during treatment

Name ondansetron (Zofran) Concentration 4 mg Dosage Amount 2 mL

Route IV Frequency PRN for nausea and vomiting
Pharmaceutical class antiemetic Home Hospital or Both
Indication as needed for nausea and vomiting
Adverse/ Side effects headache, constipation, diarrhea, dizziness, drowsiness, extrapyramidal reactions
Nursing considerations/ Patient Teaching assess for nausea, vomiting, and bowel sounds prior to administration; monitor for signs of
extrapyramidal reactions (involuntary movements, rigidity, shuffling gait)

Name naloxone (Narcan) Concentration 0.2 mg/ 0.5 mL Dosage Amount 0.2 mg until response
obtained
Route IV Frequency PRN for respiratory distress
Pharmaceutical class opioid antagonist Home Hospital or Both
Indication as needed for respiratory distress, respiration rate < 8, or unresponsive patient
Adverse/ Side effects ventricular arrhythmias, hypertension/hypotension, nausea, vomiting
Nursing considerations/ Patient Teaching monitor respiratory rate and rhythm, blood pressure, pulses and level of consciousness;
assess patient for signs of opioid withdrawal; lack of improvement indicates that symptoms are not caused by opioid overdose

Name vancomycin (Vancocin) Concentration 1250 mg/ 250 mL Dosage Amount 250 mL/ hr
Route IV Frequency infuse over 1 hour, 1 dose administered pre-surgery
Pharmaceutical class anti-infective Home Hospital or Both
Indication treatment for infection, used prophylactically prior to surgery to prevent infection
Adverse/ Side effects allergic reaction, nephrotoxicity, ototoxicity, hypotension, nausea, vomiting, phlebitis, leukopenia
Nursing considerations/ Patient Teaching assess patient frequently for infection; obtain specimens for culture prior to administration;
observe for signs of anaphylaxis; instruct patient to report signs of itching, tinnitus, vertigo, rash, hearing loss; monitor for signs of
superinfection

Hazard Vallerand, A., Sanoski, C.A., & Hopfer Deglin, J. (2016). Daviss drug guide for nurses (15th ed.).
Philadelphia, Pennsylvania: F.A. Davis Company. ISBN: 978-0-8036-5705-2

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Liquid diet until first bowel
movement, then advance as tolerated
Diet patient follows at home? Regular diet, no
restrictions. Patient states that she and her wife try to eat
healthy, avoid red meat and fried foods.
24 hour average home diet
Breakfast: egg white omelet made of 1 cup of egg whites
and cup of spinach, 3 slices turkey bacon, cup of vanilla
yogurt with granola
Analysis of home diet:
[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.]
Patients usual breakfast totals approximately 650 calories.
Breakfast includes 1 ounce of grains, cup of vegetables,
cup of dairy and 3 ounces of protein. Breakfast does not
include any fruits.

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Lunch: Caesar salad with grilled chicken breast
Dinner: grilled Halibut (with seasoning), roasted zucchini
(with olive oil, sat & pepper), baked potato (with butter and
sour cream)
Snacks: cup of grapes
Liquids (include alcohol): 1 glass of orange juice, 5
glasses of water, 1 diet Coca Cola
Patients usual lunch totals approximately 322 calories.
Lunch consists of cup of vegetables, cup of dairy, 3
ounces of protein and ounce of grain. Lunch does not
include any fruit.
Patients usual dinner totals approximately 581 calories.
Dinner consists of 2 cups of vegetables, cup of dairy
and 5 ounces of protein. Dinner does not include any fruit
or grains.
Patients usual snack totals approximately 120 calories and
consists of 1 cup of fruit.
Overall, the patient daily diet includes 1,730 calories which
falls within the recommended caloric intake for an adult
female; recommended caloric intake is between 1,600 and
2,000 calories per day. The patient consumes 135% of the
recommended intake of vegetables per day and about 80%
of the recommended fruit per day. In an effort to increase
the amount of fruit consumed each day, the patient could
add a piece of fruit to her lunch or as an extra snack
throughout the day. This would add in some extra calories
to keep her energized and increase her fruit intake. The
patient only consumes 22% of the daily recommended
whole grain consumption. In an effort to eat a more
balanced diet, the patient could add in a cup of healthy,
whole grains to her dinner like quinoa or brown rice. On
average, the patient consumes 11 ounces of protein per day
which is well over the daily recommended intake of 5
ounces. In order to reduce the amount of protein in the diet,
the patient could eat smaller portions throughout the day.
The patient could make an omelet with only cup of egg
whites and add in more vegetables for breakfast.
Additionally, the patient consumes roughly 3,679 mg of
sodium per day, which is significantly more than the
recommended 2,300 mg. This patient also has a history of
hypertension so it would be beneficial to her health if we
could decrease the amount of sodium consumed per day to
less than 2,300 mg. this could be accomplished by
removing the turkey bacon and diet soda in the diet, or
eating and drinking these types of food on occasion rather
than on a daily basis. The patient is maintaining a diet low
in saturated fat and added sugar, consuming only 13 grams
of saturated fat and 22 grams of added sugar per day.
(Information obtained from www.choosemyplate.gov,
supertracker )

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill? Patient states that her wife mainly cares for her when she is ill. Patient stated that her
wife is very good about staying on top of her medications and doctors appointments. Patient has had surgery in the past
and stated that she relied on her wife during that recovery period and she will do the same for this surgery.

How do you generally cope with stress? or What do you do when you are upset? Patient states that her main source of
stress is work. Patient is a real estate agent and struggles with the long hours and weekends that she has to work. Patient
states she tries to relieve stress by spending time with her wife and doing activities they enjoy together.

University of South Florida College of Nursing Revision September 2014 5

Recent difficulties? Patient states that she has not experienced any recent difficulties. Patient states she experienced some
anxiety in the weeks leading up to the surgery because she had to clear her work schedule and was nervous in general
about the procedure. Patient did state she does worry about her finances as her income can vary month to month, but says
she is not having any financial troubles at the moment.

+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? 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? NA
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs.
Guilt Industry vs. Inferiority Identity vs. Role Confusion/Diffusion 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: According to Erik Erikson, the goal of generativity is to be creative and productive. Often this is
accomplished through work or relationshipsThe person who fails to achieve generativity (the desire and motivation to guide the
next generation) may manifest stagnation in the form of superficial relationships and self-absorption (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is still in the generativity stage of development as she is in her mid-fifties and spends her days being a productive member
of society. The patients wife was at the bedside throughout the day and it was clear from their interactions, and my conversations with
them both, that they have a healthy marriage that provides both of them with a lot satisfaction. The patient works as a real estate agent
and it was clear through her actions and our conversations that she thoroughly enjoys her job.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: This
hospitalization did not seem to have a major impact on the patients developmental stage. The patient was busy during the afternoon
working on her computer- emailing back and forth with her clients and looking at new properties. It was clear that she would be ready
to resume her normal life as soon as she is recovered from surgery.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Patient states that she is still not sure how she developed such a
serious back issue as she never had a major accident, like a car accident that would have caused this to occur. Patient
states that aside from smoking for many years, she has taken good care of herself over the years and does not think she did
anything to cause this.
What does your illness mean to you? Patient did not really have an answer to this question. Patient stated it meant she
had a back problem and she hopes this surgery is a cure so that she doesnt have any more issues with her back.

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+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? Currently does not use any measures of protection.
How long have you been with your current partner? 12 years
Have any medical or surgical conditions changed your ability to have sexual activity? No
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy? No

University of South Florida College of Nursing Revision September 2014 7

1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life? Religion plays an important role in my life.
My wife and I consider ourselves Christians. It took us a while to find a church that was a good fit for us. I grew
up Catholic and never felt accepted, but we found a great non-denominational church that we love going to.
More than anything we love the friendships weve developed.

Do your religious beliefs influence your current condition? I wouldnt say my beliefs affect my health other
than that I just try to live a good, positive life in general.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? cigarettes How much?(specify daily amount) For how many years? 24 years
1.5 packs per day (age 26 thru 50)
If applicable, when did the
Pack Years: 44
patient quit? 8 years ago
Has the patient ever tried to quit? Yes
Does anyone in the patients household smoke tobacco? No
If yes, what did they use to try to quit? Nicotine patch,
If so, what, and how much? NA
nicotine gum, hypnosis therapy

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Beer, wine, liquor How much? 2-4 drinks For how many years? 29
Volume: 8 ounces (age 21 thru 50)
Frequency: 1-2 times per month
If applicable, when did the patient quit? NA

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Patient states that she tried marijuana on 2 or 3 occasions, but that was the extent of her drug use.
How much? NA For how many years? NA
Is the patient currently using these drugs? If not, when did he/she quit?
Yes No NA

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No

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

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: patient
does not regularly wear sunscreen, when Diverticulitis Life threatening allergic reaction
she does she wears any SPF
Bathing routine: showers 1-2 X per day Appendicitis Enlarged lymph nodes
Other: NA Abdominal Abscess Other: NA
Last colonoscopy? 2015, results were
negative
HEENT Other: NA Hematologic/Oncologic
Difficulty seeing Anemia
Cataracts or Glaucoma Genitourinary Bleeds easily
Difficulty hearing Dysuria Bruises easily
Ear infections Hematuria Cancer
Sinus pain or infections Polyuria Blood Transfusions
Nose bleeds Kidney stones Blood type if known: O positive
Post-nasal drip Nocturia Other: NA
Oral/pharyngeal infection Bladder or kidney infections
Normal frequency of urination: 6 times per
Dental problems
day
Metabolic/Endocrine
Routine brushing of teeth 2-3
Diabetes Type:
times/day
Routine dentist visits 2 times/year Hypothyroid /Hyperthyroid
Vision screening 1
Intolerance to hot or cold
time/year
Other: patient wears glasses for vision
Osteoporosis
problems- hyperopia
Other: NA
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? 2015 Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche 14 years old Encephalitis
Last CXR? menopause 49 years old Meningitis
Date of last Mammogram & Result: 2013,
Other: NA Other: NA
results were normal
Date of DEXA Bone Density & Result:
patient denies ever receiving a DEXA scan
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety

University of South Florida College of Nursing Revision September 2014

 Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other: NA
CHF
Murmur Musculoskeletal Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: NA Injuries or Fractures Other: NA
Other: NA
General Constitution
Recent weight loss or gain
How many lbs? NA
Time frame? NA
Intentional? NA
How do you view your overall health? Overall, patient states that she is in good health. Is hopeful that physical condition will improve
after her back surgery.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No
Any other questions or comments that your patient would like you to know? No

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:

General Survey: Patient Height: 510 Weight: 77.4 kg BMI: 24.4 Pain: 4 on a 0 to 10 scale
is a 58 year old female in Pulse: 79 Blood Pressure: 122/69 taken on the
no acute distress. Patient Respirations: 17, right forearm with blood pressure
is awake, alert and bilaterally equal, machine
oriented X 4. unlabored, normal
work of breathing
Temperature: 98.3 SpO2: 99% Is the patient on Room Air or O2:
degrees F (oral) Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud

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
Central access device Type: PIV, 20 gauge Location: Right forearm Date inserted: 10/6/2016
Fluids infusing? No Yes: lactated ringers and dextrose 5% with 0.45% NaCl & 20 mEq KCl

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 & left ear: 12 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth appear clean with no visible signs of decay, no cracks or damage observed, gums and oral mucosa are pink
and moist, tonsils are symmetrical and of normal size
Comments: None

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: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: clear throughout
RUL: CL LUL: CL
RML: CL LLL: CL
RLL: CL

Cardiovascular: No lifts, heaves, or thrills

Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No
JVD

University of South Florida College of Nursing Revision September 2014

 Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Patient was not on telemetry, no ECG tracing to interpret.

Calf pain bilaterally negative Pulses bilaterally equal

Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
No temporal or carotid bruits Edema: none
Location of edema: none
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 9/28/2016) 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 became nausea and vomited after walking this morning, patient was
given Zofran and encouraged to rest and nausea/vomiting subsided
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems

Other Describe: NA

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 750 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness: not assessed due to patients back pain and the location of surgical incision

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at RUE: 5 LUE: 5 RLE:5 & LLE: 5
[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
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:
Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: negative Babinski: negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normal as well as
abnormal, include rationale and analysis. List dates with all labs and diagnostic tests):

University of South Florida College of Nursing Revision September 2014

Lab Dates Trend Analysis
MRI 09/2016 N/A MRI results revealed
spinal stenosis in the
lumbar region of the
spine.
WBC 10.5 09/30/2016 Lab results prior to the The WBC count is within
surgery were not normal limits. I would
available in the chart so a expect to see an elevated
trend cannot be WBC count if the patient
determined. were to develop an
infection post-surgery.
The WBC count may be
slightly elevated after
surgery as the
inflammatory process
begins due to the tissue
damage experienced.
Hgb 9.4 09/30/2016 Lab results prior to the The Hgb is right on the
surgery were not border of being within
available in the chart so a normal limits and is an
trend cannot be indication that the patient
determined. lost blood during surgery.
If the Hgb count
continued to decrease, it
could indicate internal
bleeding. The Hgb level
should continue to
increase to within normal
limits.
Hct 32.9 09/30/2016 Lab results prior to the The Hct is slightly
surgery were not depressed. Similarly to
available in the chart so a the Hgb, the depression in
trend cannot be Hct may indicate blood
determined. was lost during surgery.
The Hct count should
continue to rise as the
body generates new red
blood cells.
BUN 12 09/30/2016 Lab results prior to the The BUN is within
surgery were not normal limits and is an
available in the chart so a indication that the
trend cannot be kidneys are functioning
determined. appropriately after
surgery. An elevated
BUN would indicate that
the kidneys are not
filtering the blood
properly and the
University of South Florida College of Nursing Revision September 2014
 innervation to the kidneys
may have been damaged
during surgery.
Cr 1.040 09/30/2016 Lab results prior to the The Cr is within normal
surgery were not limits and indicates that
available in the chart so a the kidneys are
trend cannot be functioning appropriately.
determined. Similarly to the BUN, an
elevated Cr would
indicate impaired kidney
functioning. Conversely,
a low Cr would indicate a
diet lacking in protein or
liver disease.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Patient underwent spinal surgery on 9/29/2016 and is currently being monitored in the neurological step-down unit
(CCT5). A neurological assessment is performed every 4 hours and the patient is constantly monitored for any
changes in level of consciousness. The patient is currently on a clear liquid diet. Diet will be advanced as tolerated
once the patient has her first bowel movement post-surgery. Vital signs are checked every four hours. Patient is
working with physical therapy and is able to ambulate with maximum assistance. Patient was receiving morphine
via PCA, but that was discharged the morning after her surgery. Pain is now being assessed every 4 hours and pain
is managed with medication as needed. Patient is assessed for nausea and nausea is managed with medication as
needed. IV site and surgical incision are assessed frequently for any signs of infection (redness, swelling, pain).
Patient is able to reposition herself in the bed, but is encouraged to move out of the bed and to the recliner during
the day. Sequential compression devices are placed on patients legs to prevent the development of deep vein
thrombosis and promote circulation of blood.

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

1. Nausea related to pain medication as evidenced by emesis and patient feelings of nausea following
analgesic administration.
2. Impaired physical mobility related to pain and surgical procedure as evidenced by reluctance to attempt
movement and maximum assistance needed with ambulation.
3. Acute pain related to back surgery as evidenced by patient report of pain and facial grimacing with
movement.
4. Risk for trauma related to balancing difficulties and numbness in both feet.
5. Risk for infection related to in-dwelling peripheral IV, hemovac drain and surgical incision.
6. Risk for imbalanced nutrition: less than body requirements related to NPO status and emesis.
7. Risk for falls related to medications (Lisinopril and morphine), use of walker when ambulating, impaired
physical mobility and numbness in feet.
8. Risk for peripheral neurovascular dysfunction related to spinal surgery.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Nausea related to pain medication as evidenced by emesis and patient feelings of nausea following analgesic administration.
Patient Goals/Outcomes
Patient will experience a reduction
in nausea and vomiting as
evidenced by verbalization of
decreased nausea.
Patient will experience a reduction
in episodes of vomiting.
University of South Florida College of Nursing Revision September 2014
Nursing Interventions to Achieve
Goal
-Assess patient for nausea and
vomiting
-Determine the source of the
patients nausea (in this case the appropriately treat the nausea, we
source was the morphine pain
medication)
-Administer Zofran as needed for
nausea/vomiting
-Provide oral care after episodes of
vomiting
-Encourage the patient to avoid
eating and drinking foods that
irritate the GI system (spicy foods,
fatty foods, caffeine beverages)
-Monitor for signs of dehydration
(increased thirst, low urine output,
headache, dizziness) and
encourage the patient to drink
plenty of fluids
Rationale for Interventions
Provide References
Nausea is a subjective experience
and the only way to assess for it is self-reported nausea as an 8 out of
to ask the patient. In order to
must know what is causing the
patients nausea. Zofran is an anti-
emetic that will reduce the
patients symptoms. Drinking
plenty of fluids will minimize
fluid loss and prevent
hypovolemia (Ackley & Ladwig,
2014).
Evaluation of Goal on Day Care
is Provided
At the start of shift, the patient
10 on a 0 to 10 scale. After
administering Zofran, providing
the patient with chicken broth to
drink and encouraging rest, the
patient rated nausea as a 2 out of
10. The patient decided that her
level of pain was manageable
without the pain medication and
she no longer wanted to be given
morphine for pain. The patient did
not experience any episodes of
nausea or vomiting for the
remainder of the shift.
 Nursing Diagnosis: Impaired physical mobility related to pain and surgical procedure as evidenced by reluctance to attempt movement and
moderate assistance needed with ambulation.
Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care is
Achieve Goal Provide References Provided
Patient will demonstrate use of -Assess the patients mobility and Providing a safe environment Patient was able to get up out of bed
walker to increase mobility. determine the cause of impaired reduces risk for falls. and walk 2 laps up and down the
physical mobility Range of motion exercises will hallway with physical therapy.
Patient will work with physical -Provide patient with a safe help prevent muscle weakening Patient was able to get out of bed
therapy 1Xdaily to increase environment: bed in low position, and improve balance. each time she needed to use the
mobility and maintain muscle call light and other items within Allowing the patient to participate restroom with the help of a walker.
strength. reach in ADLs allows them to regain
-Encourage patient to participate confidence in their abilities
Patient will remain free from in ADLs as much as possible (Ackley & Ladwig).
complications of immobility for -Perform range of motion
remainder of hospital stay (free exercises with the patient
from falls, skin breakdown) -Provide the patient with a walker
at the bedside and encourage
physical mobility
-Make sure patient is
repositioning herself every 2
hours to prevent skin breakdown
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, Lisinopril is available for $4 at Wal Mart, CVS and Walgreens
or for free at Publix pharmacy
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

 References

Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: an evidence-based guide to

planning care (10th ed.). Maryland Heights, Missouri: Mosby/Elsevier. ISBN: 978-0-323-

08549-6

Hazard Vallerand, A., Sanoski, C.A., & Hopfer Deglin, J. (2016). Daviss drug guide for nurses

(15th ed.). Philadelphia, Pennsylvania: F.A. Davis Company. ISBN: 978-0-8036-5705-2

National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2013). Questions and

answers about spinal stenosis. National Institutes of Health. Retrieved from

http://www.niams.nih.gov/Health_Info/Spinal_Stenosis/

Parizel, P.M., Van Hoyweghen, A.J.L., Bali, A., Van Goethem, J., & Van Den Hauwe, L. (2016).

The degenerative spine: Pattern recognition and guidelines to image interpretation.

Handbook of Clinical Neurology, 136, 787-808. doi: 10.1016/B978-0-444-53486-

6.00039-9

Treas, L.S., & Wilkinson, J.M. (Eds.). (2014). Basic nursing: concepts, skills, & reasoning.

Philadelphia, Pennsylvania: F.A. Davis Company. ISBN 978-0-8036-2778-9

United States Department of Agriculture. (n.d.). Supertracker. Retrieved from

https://www.supertracker.usda.gov/

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University of South Florida College of Nursing Revision September 2014