UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Rebecca Netjes

Assignment Date: February 28, 2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: RY Age: 68 years old Admission Date: February 2, 2016
Gender: Male Marital Status: Married Primary Medical Diagnosis: Acute pancreatitis,
sepsis
Primary Language: English
Level of Education: College Other Medical Diagnoses: Not applicable.

Occupation: Lawyer
Number/ages children/siblings: The patient’s wife stated that the
patient has no biological children. She also stated that he has a
sister, but that she does not know her age.
Served/Veteran: No. Code Status: Do Not Resuscitate (since
If yes: Ever deployed? Not applicable. 02/26/2017)

Living Arrangements: The patient’s wife states they live together Advanced Directives: None.
in a single level home. There are no other individuals residing in If no, do they want to fill them out? No.
their home. Surgery Date: 02/08/2017
Procedure: Pancreatic cyst resection and repair.
Culture/Ethnicity/Nationality: White
Religion: Unknown Type of Insurance: Humana

 1 CHIEF COMPLAINT:
On 02/02/2017, the patient presented to the Florida Hospital Emergency Department (ED) with complaints of “severe
abdominal pain that radiated to his back”. He had stated he “had just eaten dinner and had lied down to go to bed, but that
it hurt too bad to wait to see a doctor”.

 3 HISTORY OF PRESENT ILLNESS:

Upon arrival to the ED on 02/02/2017, 68-year-old male patient complained of severe abdominal pain that radiated to his
back. It was described as starting soon after eating and was constant in nature. The pain was “just too awful” and “nothing
was helping”. Significant assessment findings revealed the patient to be hypertensive, have a WBC count of 28, lipase
above 600, and a CT A/P suggested pancreatitis. The patient was admitted to the medical-surgical floor for management
with orders for a NPO diet, antibiotic therapy, IV fluids, and rest. On 02/05/2017, the patient complained of increased
abdominal pain and there were hypoactive bowel sounds. There became a concern for an ileus. An NG tube was inserted,
but a CT Chest/A/P revealed infecting necrotizing pancreatitis. The patient was transferred to the ICU. The patient
required surgery to resect pancreatic cysts and repair several that had ruptured on 02/08/2017. On 02/13/17, the patient
was found tachycardic, shivering, and short of breath. Arterial blood gasses revealed a PaO 2 of 53, and the patient was put
on BiPAP allowing him to sustain oxygen saturation of approximately 90%. A chest x-ray done on 02/13/2017 revealed
infiltrates on the left side, and blood cultures done on 02/14/17 showed gram negative rods identified as Klebsiella
pneumoniae. He was then being treated for the infection with concern of it developing into septic shock. On 02/19/2017,
the patient experienced cardiac arrest and was pulseless for 15 minutes, he was then intubated. On 02/21/2017, the patient
University of South Florida College of Nursing – Revision September 2014 1
experienced cardiac arrest for the second time at 1900 and required more aggressive hemodynamic support. On
02/26/2017, the patient’s code status was changed from full resuscitation to do not resuscitate. On 02/27/2017, the patient
was extubated and a tracheostomy was placed. Currently, the patient is still under sedation to prevent dislodgment of the
new tracheostomy. On 02/28/2017, the patient required a transfusion of packed red blood cells for a hemoglobin of 6. A
CT Chest/A/P was ordered to assess for internal bleeding as there was no external signs of bleeding.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Date Operation or Illness

Unknown Diabetes, type 2, managed with metformin.
Unknown Hyperlipidemia.

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Heart Trouble

Mental Health
Age (in years)

Hypertension
FAMILY
Bleeds Easily
Alcoholism

Cause

Glaucoma
MEDICAL

Problems

Problems
Allergies

Arthritis

Diabetes
of

Seizures
Anemia

Asthma

Cancer

Kidney

Tumor
HISTORY

Stroke
Death

Gout
(if
applicable)
Father Unknown
Mother Unknown
Sister

Comments:
The patient’s wife stated she did not have extensive knowledge regarding his family’s medical history. She stated his family all seemed
“relatively healthy” but other than that she couldn’t “answer for him”. She believes that his father and mother deaths’ were related to
cardiac events. In regards to the patient’s sister, she reported she had minimal knowledge of her medical history, but that “she hasn’t
been sick since she has known her”.

 1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria: Wife states “up to date”.
Adult Tetanus: Wife states “up to date”.
Influenza (flu) Not within one year.
Pneumococcal (pneumonia) Not within one year.
Have you had any other vaccines given for international travel or
occupational purposes?

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  1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction
Causative Agent
REACTIONS
Steroids Itching
Medications

Other (food, tape, None known.

latex, dye, etc.)

 5 PATHOPHYSIOLOGY:
Pancreatitis is simply defined as the inflammation of the pancreas. Various conditions can predispose an individual to an
episode of acute pancreatitis such as a history of alcoholism, peptic ulcers, biliary obstruction, etc. (Osborn, Wraa, Watson
& Holleran, 2014). It is not known exactly what occurs at a cellular level that induces the pancreatic inflammation, but it
is thought to be related to an increase in enzyme secretions. This overproduction of enzymes forces a portion of them into
the tissue of the pancreas itself (Osborn et al., 2014). The clinical presentation of acute pancreatitis is severe, constant pain
ranging from the epigastric region to the left side of the back that is worsened with movement. There can be
accompanying abdominal distention and hypoactive bowel sounds (Osborn et al., 2014). Diagnosis is based upon physical
assessment and lab tests, with attention to amylase and lipase, and radiographic findings. The patient diagnosed with acute
pancreatitis is treated with antibiotic therapy, a NPO diet, bed rest, and possibly a NG tube. As the patient recovers, the
nurse should encourage a slow return to a low fat diet starting with clear liquids, advancing as tolerated. Infecting
necrotizing pancreatitis is considered to be a complication of unresolved or ineffectively treated pancreatitis. Typically,
gram-negative organisms are identified, encased in capsules not penetrated by antibiotic therapy (Bendersky, Mallipeddi,
Perez, & Pappas, 2016). These organisms, along with pancreatic fluid can form “pseudocysts” which could then
potentially rupture. This allows the organisms to be released into the circulatory system – which could result in infection
at distant organ sites. As a result, patients often suffer from multiple organ failure. These patients often required multiple
interventions to manage the associated organ failure such as hemodynamic support with pharmacotherapy and mechanical
ventilation. Also, they will likely require debridement of the necrotic pancreatic tissue and antibiotic irrigation (Bendersky
et al., 2016). If sepsis, secondary to cyst rupture, is diagnosed it is likely that the patient will present with severe
hypotension, fever, and an increase in respiration and respiratory effort (Osborn et al., 2014). Sepsis will ultimately result
in organ failure as a result of hypoperfusion if left untreated. Primary goals of sepsis management involve supplemental
oxygen with mechanical ventilation if necessary, aggressive antibiotic therapy, and fluid resuscitation. If the disease
process progresses to infecting necrotizing pancreatitis, patient prognosis is generally poor and is associated with higher
levels of morbidity and mortality (Bendersky et al., 2016).

 5 MEDICATIONS:
Reference:
Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application software]. Retrieved from http://itunes.apple.com

Name: fentanyl 2500 mcg/NS 250 mL Concentration: 10 mcg/mL Dosage Amount: Start at 25 mcg/hr, titrate by 25
mcg/hr Q15 minutes, to achieve a RASS -1, notify
if physician if rate reaches max rate of 275 mcg/hr

Was set at 200 mcg at beginning of shift,

discontinued at 1130.
Route: IV Frequency: Continuous
Pharmaceutical class: Opioid Home Hospital or Both
Indication: Sedation
Adverse/ Side effects: Assess for respiratory depression, severe hypotension or bradycardia, cardiac arrest, paralytic ileus, and seizures.
Nursing considerations/ Patient Teaching: Nurse should be familiar with the RASS & how to assess. Teach family that the patient will be drowsy. Monitor for
constipation related to opioid therapy. Monitor for bradycardia and hypotension.

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Name: precedex 4 mcg/mL NaCl 0.9% Concentration: 4 mcg/mL Dosage Amount: Initially dose = infuse 1 mcg/kg
slowly over 10 min as a loading dose, followed by
0.2 mcg/kg/hr infusion, titrate 0.2 mcg/kg/hr G30
min to maintain RASS -1.

Currently, set at 1.4 mcg/kg/hr or 135 mcg.

Route: IV Frequency: Continuous
Pharmaceutical class: Opioid Home Hospital or Both
Indication: Sedation
Adverse/ Side effects: Assess for respiratory depression, severe hypotension or bradycardia, cardiac arrest, paralytic ileus, and seizures.
Nursing considerations/ Patient Teaching: Nurse should be familiar with the RASS & how to assess. Teach family that the patient will be drowsy. Monitor for
constipation related to opioid therapy. Monitor for bradycardia and hypotension.

Name: heparin 25,000 units/250 ml 0.45% sodium Concentration: 25,000 units/250 ml Dosage Amount: Start gtt with no bolus. Heparin
chloride sliding scale (weight based orders) for atrial
fibrillation.

Currently, set at 16 units.

Route: IV Frequency: Continuous
Pharmaceutical class: anticoagulant Home Hospital or Both
Indication: Prevent clots
Adverse/ Side effects: bleeding, heparin induced thrombocytopenia, urticaria, hemorrhage, hypersensitivity reaction.
Nursing considerations/ Patient Teaching: Monitor for signs and symptoms of bleeding (i.e. bruising). Communicate with provider regarding the platelet levels
and other coagulation studies. Implement bleeding precautions.

Name: norepinephrine 4mg/ DSW 250 mL Concentration: 4mg/250 mL Dosage Amount: Start 4 mcg/min, increase by 2
mcg/min Q 5 minutes to achieve MAP 65 mmHg
or greater.

Currently, set at 0.12 mg.

Route: IV Frequency: Continuous
Pharmaceutical class: vasopressor Home Hospital or Both
Indication: treat hypotension
Adverse/ Side effects: headache, bradycardia, dyspnea, hypertension, ischemic injury, asthma exacerbation, anaphylaxis
Nursing considerations/ Patient Teaching: Monitor blood pressure and heart rate in response to medication. Titrate to the lowest possible dose. Communicate
with health care provider to assess for need for medication. Assess circulation.

Name: furosemide 100 mg/ NS 0.9% 100 mL Concentration: 1 mg/mL Dosage Amount: 100 mg, infuse over 10 hours.

Currently, set at 10 mg per hour.

Route: IV Frequency: Continuous
Pharmaceutical class: loop diuretic Home Hospital or Both
Indication: fluid overload
Adverse/ Side effects: urinary frequency, nausea/vomiting, hypokalemia, diarrhea, hyperglycemia, hypovolemia, ototoxicity
Nursing considerations/ Patient Teaching: Monitor urinary output. Prevent falls if patient is ambulating to the bathroom. Monitor electrolyte levels and assess
for signs of deficiency. Assess blood pressure. Monitor for improvement in signs and symptoms of fluid overload.

Name: vasopressin 100 units/ NS 0.9% 100 mL Concentration: 1 unit/1 mL Dosage Amount: Start at 0.04 units/min. Use as
Pitressin. HIGH ALERT.

Currently, set at 2.4 units.

Route: IV Frequency: Continuous
Pharmaceutical class: vasopressor Home Hospital or Both
Indication: treat hypotension
Adverse/ Side effects: nausea, hyponatremia, diaphoresis, tremor, headache, anaphylaxis, water intoxication, tachyarrhythmia, bradycardia, myocardial
infarction
Nursing considerations/ Patient Teaching: Monitor blood pressure in response to medication. Titrate to the lowest possible dose. Communicate with health care
provider to assess for need for medication. Assess circulation.

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Name: meropenem Concentration: Dosage Amount: 500 mg

Route: IV Frequency: Every 6 hours

Pharmaceutical class: antibiotics Home Hospital or Both
Indication: Gram negative infection with MDRO
Adverse/ Side effects: nausea, vomiting, diarrhea, headache, seizures, anaphylaxis, superinfection, thrombocytopenia, agranulocytosis, neutropenia
Nursing considerations/ Patient Teaching: Nurse should monitor CBC for blood dyscrasia. Assess for allergies prior to administration. Teach patient signs and
symptoms of infection to report to healthcare provider. Teach patient/family to take entire course of medication, even if they are feeling better. Monitor for
therapeutic effectiveness of antibiotic.

Name: insulin glargine (Lantus) Concentration: 100 units/1 mL Dosage Amount: 15 units

Route: subcutaneous injection Frequency: 2 times daily

Pharmaceutical class: insulin Home Hospital or Both
Indication: hyperglycemia, history of type 2 diabetes
Adverse/ Side effects: hypoglycemia, hypokalemia, injection site lipodystrophy, weight gain, edema, hypersensitivity reaction
Nursing considerations/ Patient Teaching: Teach patient that this insulin is long acting, to establish basal rate. Monitor for signs or symptoms of hypoglycemia
such as diaphoresis or headache. Nurse should monitor blood glucose level prior and after administration. Nurse should be aware of/assess for Dawn
Phenomenon and Somogyi Effect.

Name: insulin lispro Concentration: 100 units/1 mL Dosage Amount: sliding scale – “glucose control
for critically ill”
Route: subcutaneous injection Frequency: Every 4 hours
Pharmaceutical class: antibiotics Home Hospital or Both
Indication: hyperglycemia, history of type 2 diabetes
Adverse/ Side effects: hypoglycemia, hypokalemia, injection site lipodystrophy, weight gain, edema, hypersensitivity reaction
Nursing considerations/ Patient Teaching: Teach patient that this insulin is rapid acting. The patient should be aware that they will need to eat within 5-15
minutes of administration. Monitor for signs or symptoms of hypoglycemia such as diaphoresis or headache. Nurse should monitor blood glucose level prior and
after administration.

 5 NUTRITION:
Diet ordered in hospital? NPO, total parenteral nutrition Analysis of home diet:
Diet patient follows at home? I am unable to analyze the diet that the patient follows at
24 HR average home diet: Unable to assess per sedation of home as he is sedated. Given his history, I would advise
patient. my patient to consider a diet that is low in carbohydrates
Breakfast: and fats. He has a history of type 2 diabetes and
hyperlipidemia. It would be critical that the patient
monitor his intake of carbohydrates as they could cause a
Lunch: rapid increase in his blood glucose. His body is unable to
efficiently create insulin to cope with this alteration. I
Dinner: would advise him that foods that are lower in
carbohydrates and higher in protein will not cause rapid
Snacks: changes in glucose, but rather a steady, slow increase. I
would also advise him to monitor for signs and symptoms
of hyper/hypoglycemia. For his hyperlipidemia, I would
Liquids: advise him to consider a diet low in fat. If he were to have
an increase in his LDL and a decrease in his HDL, he
could develop atherosclerosis. This is a significant risk for
factor for many cardiac disease processes. Currently, he is
on a total parenteral nutrition diet. I would continue to
monitor for signs of malnutrition or electrolyte imbalances.
No home diet data available for MyPlate graphs.

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1 COPING ASSESSMENT/SUPPORT SYSTEM:
Who helps you when you are ill?
With regards to this current situation, the patient’s wife and daughter have been his primary caregivers. However, because
of his level of sedation, I am unable to assess fully.

How do you generally cope with stress? or What do you do when you are upset?
Unable to assess per level of sedation.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
The patient’s wife states “this has been the most difficult thing of their life”. I am unable to assess patient response per
level of sedation.

+2 DOMESTIC VIOLENCE ASSESSMENT:

Have you ever felt unsafe in a close relationship? Unable to assess per level of sedation.

Have you ever been talked down to? Unable to assess per level of sedation.
Have you ever been hit punched or slapped? Unable to assess per level of sedation.

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Unable to assess per level of sedation.

If yes, have you sought help for this? Unable to assess per level of sedation.

Are you currently in a safe relationship? The patient has been married to his wife for more than 30 years. However, I
am unable to assess patient response to question per level of sedation.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 of both parts of Erickson’s developmental stage for your patient’s
age group:
Generativity is defined as the “ability to love deeply and commit oneself” and stagnation is “emotional isolation;
egocentricity” (Halter & Varcarolis, 2014, p. 23). The task associated with this relationship is accomplishing goals and
establishing concern for future generation. It is typically resolved in middle adulthood.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
Through observation of the patient, review of the clinical record, and limited conversation with the patient’s family, it
appears that the patient is in the stage of generativity versus stagnation. Prior to this hospitalization, the patient’s family
recounted that he is a successful lawyer and loving family member. His wife stated that “he was so kind and loving to her
– her better half”. It seems as though he was continuing to build and create new life experiences. He seems to be resolving
this stage with the outcome of “generativity”. However, this hospitalization could complicate his ability to move forward.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
This hospitalization has caused the patient to be dependent on others for care. He is severely limited in his functional
abilities. This poses a threat to his developmental stage as he could easily transition to stagnation rather than generativity.
At this point, his seems to be regaining strength and health as his labs are beginning to trend back to within normal limits
and he was able to be transitioned to a tracheostomy. With continued medical care and family support, he may be able to
continue on his path toward generativity.

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 +3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Unable to assess per level of sedation.

What does your illness mean to you?

This patient’s illness has significantly decreased his functionality and independence. His wife states “this is the hardest
thing they have been through”. She is scared he won’t come home. However, I am unable to assess patient response to
question per level of sedation.

+3 SEXUALITY ASSESSMENT:

Have you ever been sexually active? Yes.

Do you prefer women, men or both genders? Unable to assess per level of sedation.
Are you aware of ever having a sexually transmitted infection? Unable to assess per level of sedation.
Have you or a partner ever had an abnormal pap smear? Unable to assess per level of sedation.
Have you or your partner received the Gardasil (HPV) vaccination? Unable to assess per level of sedation.

Are you currently sexually active? Not since 02/02/2017 (date of hospitalization).
If yes, are you in a monogamous relationship?
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? Unable to assess per level of sedation.

How long have you been with your current partner? “30 years” per report by patient’s wife.

Have any medical or surgical conditions changed your ability to have sexual activity? Patient’s wife denies
knowledge of any conditions.

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy? Unable to assess per level of sedation.

±1 SPIRITUALITY ASSESSMENT:

What importance does religion or spirituality have in your life? The patient’s wife does not report a religious belief.
However, unable to assess per level of sedation.

Do your religious beliefs influence your current condition? The patient’s wife states she has felt like “she should be
praying for him, as that is all she feels like she can do”. She “just wants him to be better”. Unable to assess patient
response per level of sedation.
____________________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
Yes No (per report by patient’s wife).

If so, what? How much? (specify daily amount) For how many years?

(age through )
If applicable, when did the
Pack Years:
patient quit?
Does anyone in the patient’s household smoke tobacco? Has the patient ever tried to quit?
University of South Florida College of Nursing – Revision September 2014 7
If so, what, and how much? If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes (per report by patient’s wife) No
How much? Unable to assess per
What? Unable to assess, per sedation level.
level of sedation. Wife states “not that
Wife states she does not know “his favorite”. For how many years?
much”.
Volume:
Frequency: (age Unknown through 51 )
If applicable, when did the patient quit? 17
years ago, per patient’s wife’s report.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?

Yes No (per report by patient’s wife)

How much? For how many years?
(age through )
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental hazards/risks?
Unable to assess per level of sedation.

5. For Veterans: Have you had any kind of service related exposure?
Unable to assess per level of sedation.

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 10 REVIEW OF SYSTEMS NARRATIVE
Information gathered by report from patient’s wife and review of medical history listed in medical record.

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: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia 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: AB Positive
Post-nasal drip Normal frequency of urination: Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems: dentures Other: Metabolic/Endocrine
Routine brushing of teeth: Diabetes Type: 2
Routine dentist visits: Hypothyroid /Hyperthyroid
Vision screening: Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing – Intubation 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? Seizures
Tuberculosis menstrual cycle Ticks or Tremors
Environmental allergies menarche Encephalitis
last CXR? 02/13/2017 menopause Meningitis
Other: Date of last Mammogram & Result: Other:
Date of DEXA Bone Density & Result:
Other:
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
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
University of South Florida College of Nursing – Revision September 2014 9
 Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias: Osteomyelitis Scarlet Fever
Last EKG screening: Continuous
Arthritis Chicken Pox
Telemetry
Other: Other: Other:
General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?

How do you view your overall health? Unknown.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Unable to assess per level of sedation.

Any other questions or comments that your patient would like you to know?
Unable to assess per level of sedation.

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±10 PHYSICAL EXAMINATION:

General Survey: Patient is a Height: 174 cm Weight: 96.8 kg BMI: 31.9 Pain: At time of assessment,
68-year-old male that does Pulse: 80 Blood Pressure: 141/53, MAP 76, the patient did not exhibit
not exhibit signs or Respirations: 20 Right Arterial Line signs or symptoms of pain.
symptoms of distress. He is He has had a -1 for his
resting in bed. RASS score, during this
Temperature: 99.5, axillary SpO2: 93, FiO2 60 Is the patient on Room Air or O2 shift.
Ventilator/Tracheostomy
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
Other: Patient is sedated for protection of the newly placed tracheostomy. He appears to be resting comfortably in bed. He
has a RASS score of -1 during this shift. During sedation vacation, he became mildly agitated.

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

clear, crisp diction
Other: Not any, the patient has a tracheostomy.

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other: Agitated during sedation vacation.

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
Other: Skin is noted to be pale.

Central access device Type: 2 Lumen High Flow PICC Location: Left basillic vein Date inserted: 02/05/17
Fluids infusing? no yes
no redness, edema, or discharge

Central access device Type: 3 Lumen CVC Location: Left internal jugular Date inserted: 02/27/17
Fluids infusing? no yes – D10 or NS
no redness, edema, or discharge

Peripheral IV site Type: 20 gauge Location: Right AC Date inserted: 02/20/2017

no redness, edema, or discharge
Fluids infusing? no yes

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 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Other: At times, the patient’s mucosa is dry- oral care was provided three times.
Dentition: Dentures for upper teeth. Lower teeth reveal no abnormalities.

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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:
RUL: CR LUL: CR RLL: CR
RML: CR LLL: CR
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
Other: Patient extubated yesterday, with tracheostomy placed. No complications noted.

Cardiovascular: No lifts, heaves, or thrills

Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No
JVD
Rhythm:
Throughout the patient’s hospitalization, he had intermittent atrial fibrillation. Currently, the patient has sustained
sinus rhythm. The rate below is 69 bpm. There is a P wave prior to every QRS complex, with a T wave following. I
would continue to monitor the patient’s rhythm, as well as response and clinical presentation.

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: 2 Femoral: Popliteal: DP: 2 PT:
No temporal or carotid bruits Edema: +2 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: lower extremities pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

GI: Bowel sounds normoactive 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: 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 Not assessed, patient alert, oriented, denies
problems
Other: Hypoactive bowel sounds. Nasogastric tube inserted. Scrotum enlarged and distended.

GU: Urine output: Clear Cloudy Color: Yellow Hourly: approximately 130 mL/hr
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: Full ROM intact in all extremities without crepitus (Passive ROM)
Strength bilaterally equal at: 3 RUE 3 LUE 3 RLE & 3 in LLE (during sedation vacation)

[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

University of South Florida College of Nursing – Revision September 2014 12

 Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Other: Neurovascular status: peripheral pulses are palpable and there is no pallor, unable to assess patient response with
regards to pain or paresthesia. Patient does not exhibit signs or symptoms of distress.

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 Romberg’s 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
Other: Patient is sedated for protection of newly placed tracheostomy, unable to assess orientation. During sedation
vacation the patient responds to tactile stimuli and can obey commands such as to move his fingers. Unable to assess
gait and Romberg’s as patient is on bed rest.

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Lab Dates Trend Analysis

WBC (normal 4.5-11) The patient’s WBC The patient was admitted with
fluctuated throughout his pancreatitis. This infection would
28.0 k/mcL H 02/02/2017 hospitalization. Currently, cause the WBC count to rise. Later in
it has been trending down. his hospitalization, the patient acquired
11.8 k/mcL H 02/13/2017 Klebsiella pneumoniae- another
infection. This resulted in another
20.6 k/mcL H 02/19/2017 increase in WBC count. It is currently
trending down, likely because of the
22.0 k/mcL H 02/27/2017 antibiotic therapy. I would continue to
monitor.
12.5 k/mcL H 02/28/2017

Hemoglobin (normal 12-16) At the beginning of his The patient does not exhibit signs or
hospitalization, the symptoms of bleeding (i.e. frank
14 gm/dL 02/02/2017 patient’s hemoglobin was blood, bruising, hypotension).
within normal limits. However, there was not another cause
8.3 gm/dL L 02/13/2017 However, it is currently identified for his decrease in
trending downwards. hemoglobin. Packed red blood cells
8.6 gm/dL L 02/19/2017 were transfused on 02/28/2017 and CT
Chest/A/P was done to assess for
7.3 gm/dL L 02/27/2017 bleeding. I would continue to monitor.

6.0 gm/dL L 02/28/2017

Hematocrit (normal 36-45) At the beginning of his The patient does not exhibit signs or
hospitalization, the symptoms of bleeding (i.e. frank
46.4 % 02/02/2017 patient’s hematocrit was blood, bruising, hypotension).
within normal limits. However, there was not another cause
26.9 % L 02/13/2017 However, it is currently identified for his decrease in
trending downwards. hematocrit. Packed red blood cells
28.8 % L 02/19/2017 were transfused on 02/28/2017 and CT
Chest/A/P was done to assess for
24.1 % L 02/27/2017 bleeding. I would continue to monitor.

19.6 % L 02/28/2017

University of South Florida College of Nursing – Revision September 2014 13

Platelets (normal 150- 450) At the beginning of his On 02/19/2107, the patient received a
hospitalization, the transfused of packed red blood cells
380 k/mol 02/02/2017 patient’s platelets were after cardiac arrest. The patient does
within normal limits. not exhibit signs or symptoms of
263 k/mol 02/13/2017 However, it is currently bleeding (i.e. frank blood, bruising,
trending downwards. hypotension). However, there was not
494 k/mol H 02/19/2017 another cause identified for his
decrease in platelets. Packed red blood
245 k/mol 02/27/2017 cells were transfused on 02/28/2017
and CT Chest/A/P was done to assess
150 k/mol 02/28/2017 for bleeding. I would continue to
monitor.
Sodium (normal 133-145) The patient’s sodium level As the patient’s sodium levels were
was within normal limits within normal limits, it is expected that
138 mEq/L 02/02/2017 throughout his entire stay he would not experience any signs or
at the hospital. symptoms of disturbance. I would
133 mEq/L 02/13/2017 continue to monitor for changes as he
is on several regimens that could alter
140 mEq/L 02/19/2017 his electrolyte levels (i.e. furosemide
therapy).
135 mEq/L 02/27/2017

137 mEq/L 02/28/2017

Potassium (normal 3.5-5) The patient’s potassium As the patient’s potassium levels were
level was within normal within normal limits, it is expected that
4.2 mEq/L 02/02/2017 limits throughout his entire he would not experience any signs or
stay at the hospital. symptoms of disturbance. I would
3.7 mEq/L 02/13/2017 continue to monitor for changes as he
is on several regimens that could alter
4.1 mEq/L 02/19/2017 his electrolyte levels (i.e. furosemide
therapy).
4.5 mEq/L 02/27/2017

3.5 mEq/L 02/28/2017

Chloride (normal 95-105) The patient’s chloride The patient did not exhibit signs or
level was within normal symptoms of a chloride disturbance. I
100 mEq/L 02/02/2017 limits for the majority of would continue to monitor for a
the hospitalization, but has chance in clinical presentation. I would
96 mEq/L 02/13/2017 recently been trending also collaborate with the health care
down. provider to establish if there is a need
102 mEq/L 02/19/2017 for replacement therapy.

91 mEq/L L 02/27/2017

86 mEq/L L 02/28/2017

CO2 (normal 21-32) The patient’s CO2 level
was within normal limits
20 mEq/L L 02/02/2017 for the majority of his
hospitalization, but has
25 mEq/L 02/13/2017 recently been trending
upwards.
Typically, a rise in CO2 indicates a
change in perfusion or decrease in
ventilation. This patient is on a
ventilator but was just transitioned to a
tracheostomy from an endotracheal
tube. I believe that this is in relation to

University of South Florida College of Nursing – Revision September 2014 14

 23 mEq/L 02/19/2017 his body having to engage in more of
the work of breathing as we have been
35 mEq/L H 02/27/2017 increasing time on sedation vacation.
Respiratory therapy has also adjusted
39 mEq/L H 02/28/2017 his ventilator settings during that time.
I would continue to collaborate with
respiratory therapy with regards to this
level.
Glucose (normal 70-100) The patient’s glucose level It is expected that his blood glucose
was high throughout entire would be elevated because he has a
282 mg/dL H 02/02/2017 admission. history of diabetes type 2. At home he
manages this with metformin. While in
213 mg/dL H 02/13/2017 the hospital we are managing with
insulin. His elevation in blood glucose
301 mg/dL H 02/19/2017 could also be related to a stress
response or infusion of D10 fluids and
231 mg/dL H 02/27/2017 TPN. I would continue to monitor this.

113 mg/dL H 02/28/2017

BUN (normal 7-20) The patient’s BUN was The patient is an acute infectious state
elevated throughout the requiring multiple pharmacologic
22 mg/dL H 02/02/2017 majority of the admission. interventions. His kidneys could be
experiencing an acute injury related to
17 mg/dL 02/13/2017 the extra work of filtering the
medication and toxins.
83 mg/dL H 02/19/2017

44 mg/dL H 02/27/2017

52 mg/dL H 02/28/2017

Creatinine (normal 0.6 to 1.1) The patient’s creatinine As the patient’s creatinine levels were
was relatively normal within normal limits, it is expected that
1.0 mg/dL 02/02/2017 throughout admission. he would not experience any signs or
symptoms of disturbance. I would
0.6 mg/dL 02/13/2017 continue to monitor for changes.

1.4 mg/dL H 02/19/2017

0.8 mg/dL 02/27/2017

1.0 mg/dL 02/28/2017

Troponin T (normal 0.00-0.03) The patient’s troponin was This level was evaluated to be sure that
normal at admission, and the pain he was experiencing was not
< 0.01 ng/L 02/02/2017 was not assessed again related to cardiac injury. I would
during admission. continue to monitor.

Lipase (normal 0-160) The patient’s lipase level This level indicates severe pancreatitis
was extremely elevated at which was the patient’s admitting
> 600 U/L H 02/02/2017 admission. diagnosis.

University of South Florida College of Nursing – Revision September 2014 15

 proBNP (normal 0) The patient’s proBNP This level was drawn after the patient
level was elevated during experienced cardiac arrest. It is
999 H 02/20/2017 admission. expected that his proBNP would be
elevated after a cardiac event. I would
continue to monitor.
Arterial Blood Gas (ABG) During admission, the The patient was acutely dyspneic on
patient became acidotic at 02/13/2017. On this day, it was found
pH 7.371 02/13/2017 times. The patient’s PCO2 that he had infiltrates in his left lung.
PCO2 45.5 H was elevated during The elevation in his PCO2 is likely
PO2 53.2 L admission, but had begun related to a decrease in respirations,
HCO3 26.4 H to trend downwards. The causing CO2 retention. Also the PO2
O2 Sat 85.9 L patient’s PO2 was low and O2 Sat were found to be low as a
throughout admission, but result of an inability to perfuse oxygen
pH 7.239 L 02/19/2017 had been trending at the capillary membranes. On
PCO2 63.2 H upwards. The patient’s 02/19/2017, the patient experienced
PO2 77.0 L HCO3 had been high cardiac arrest. On this day, he was
HCO3 27 H during admission, and was pulseless for 15 minutes and required
O2 Sat 94.6 still trending upwards. The intubation. This elevation in PCO2 and
patient’s O2 Sat had been decrease in PO2 is largely related to the
pH 7.390 02/27/2016 low during admission, but body’s inability to perfuse as a result
PCO2 63.4 H had been within normal of no circulation. He became acidotic
PO2 76.0 L limits. as the CO2 rose and PO2 declined.
HCO3 38.3 H Now, the PCO2 is trending down as the
O2 Sat 96 patient is receiving ventilatory support
from the mechanical ventilation. Also,
pH 7.437 02/28/2017 the ventilator was set on an FiO2 of 60,
PCO2 62.2 H allowing the patient’s PO2 and O2 Sat
PO2 126 H to trend upwards. I would continue to
HCO3 41.9 H monitor these values.
O2 Sat 99.6

02/02/2017 CT A/P indicated for severe abdominal pain: pancreatitis

02/05/2017 CT Chest/A/P indicated for suspected ileus: infecting necrotizing pancreatitis

02/13/2017 CXR for decrease in PaO2 and shortness of breath: infiltrates on left side

02/28/2017 CT Chest/A/P indicated for suspected bleed: results pending

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

1. Admitted to ICU for treatment and management of pancreatitis and sepsis.
2. Currently, patient is being followed by respiratory therapy for management of mechanical ventilation.
3. Current mechanical ventilation settings: FiO2: 60, Mode: CMV/AC, Tidal Volume: 420, PEEP: 8, Rate:
20
4. Patient is being followed by nephrology, gastroenterology, pulmonology, and cardiology.
5. Vital signs are ordered per unit routine, with continuous telemetry and continuous arterial pressure
monitoring.
6. Diet is ordered as NPO with total parenteral nutrition support.
7. Physical Therapy and Occupational Therapy to consult/assess this week.
8. Nasogastric tube insertion.
9. Blood transfusion for hemoglobin below 7.
University of South Florida College of Nursing – Revision September 2014 16
  8 NURSING DIAGNOSES:
1. Decreased cardiac output related to septic shock and intermittent arrhythmia as evidenced by need for
pharmacologic hemodynamic support, pallor, and decreased peripheral pulses (radial and dorsal pedal, 2+,
bilaterally).
2. Impaired spontaneous ventilation related to septic shock as evidenced by decreased PO 2 (53.2, 77, 76),
dyspnea, and need for mechanical ventilation since 02/21/2017.
3. Delayed surgical recovery related to post-operative surgical infection as evidenced by two cardiac arrests,
need for mechanical ventilation, and hemodynamic instability.
4. Risk for disuse syndrome related to altered level of consciousness (sedation) and prescribed bedrest.
5. Risk for caregiver role strain related to potential discharge of family members to home with significant
care needs.

University of South Florida College of Nursing – Revision September 2014 17

± 15 CARE PLAN

Reference: Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights, MO:
Mosby/Elsevier.

Nursing Diagnosis: Decreased cardiac output related to septic shock and intermittent arrhythmia as evidenced by need for pharmacologic
hemodynamic support, pallor, and decreased peripheral pulses (radial and dorsal pedal, 2+, bilaterally).

Patient Goals/Outcomes
Patient will have systolic blood
pressure above 110 mmHg, and
diastolic above 70 mmHg, and
mean arterial pressure (MAP)
above 65 mmHg during entire
shift.
Nursing Interventions to
Achieve Goal
Titrate inotropic/vasoactive
medications within defined
parameters to maintain blood
pressure per physician’s orders.
Rationale for Interventions
Hemodynamic support for the
patient in septic shock allows
healthcare professionals to exert a
tight control on blood pressure to
prevent organ damage from
hypoperfusion.
Evaluation of Goal on Day Care
The patient’s objective data and
clinical presentation was
monitored. His pharmacologic
therapy including vasopressin and
norepinephrine was maintained,
and titration was not indicated.

Patient will be free from
arrhythmia and have a heart rate
between 60 and 100 beats per
minute during entire shift.
Monitor blood pressure and MAP
through the use of arterial line,
after zeroing the transducer.
Perform and analyze an
electrocardiogram (ECG) of the
heart once each shift, or as
clinically indicated.
Invasive monitoring systems allow
health care professionals to have
continuous information regarding
the patient’s hemodynamic status.
Arrhythmias are irregular
contraction patterns of the
myocardial cells, and lead to a
decrease in cardiac output,
decreasing blood pressure.
The arterial line was zeroed at the
beginning of shift and after any
change in patient position. His
MAP was maintained above 65
mmHg.
An ECG was performed at the
beginning of shift, showing sinus
rhythm. This was discussed and
analyzed with the attending
physician. A repeat ECG was not
indicated at this time.

Monitor for electrolyte Many times, the cause of a cardiac The patient’s sodium and
imbalances, with attention to event is attributed to an electrolyte potassium were within normal
serum potassium levels, that could imbalance. Most frequently, this is limits, and the chloride was low.
contribute to dysrhythmia. due to hyperkalemia as the excess The physician was made aware,
prohibits the myocardial cells from but did not order intervention.
University of South Florida College of Nursing – Revision September 2014 18

Patient will have exhibit radial and
dorsal pedal pulses at 3+
bilaterally by end of week.
University of South Florida College of Nursing – Revision September 2014
Assess peripheral pulses for rate
and strength, bilaterally, each day
and document findings.
Provide hydration with
intravenous fluids and transfuse
blood or blood products when
clinically indicated and ordered.
depolarizing in a synchronized,
organized manner.
Assess the quality of peripheral
pulses each day allows the
healthcare team to trend changes
in patient’s status.
In order for a patient to have a
cardiac output and peripheral
pulses within normal parameters
they must have an adequate fluid
volume.
Peripheral pulses were assessed at
the beginning of the shift as well
as after administration of packed
red blood cells with fluids. The
patient maintained radial and
dorsal pedal pulses at 3+
bilaterally, this shift.
The patient was receiving a
continuous infusion of NS or D10
(as nutrition supplement). He also
received a transfusion of packed
red blood cells. Fluids were given
on time, when indicated or
ordered, this shift.
19
Nursing Diagnosis: Impaired spontaneous ventilation related to septic shock as evidenced by decreased PO 2 (53.2, 77, 76), dyspnea, and need for
mechanical ventilation since 02/21/2017.

Patient Goals/Outcomes
Patient will exhibit normal O2
(>94%) and PaO2 (> 80 mmHg)
levels this shift.
Nursing Interventions to
Achieve Goal
Explain intubation and mechanical
ventilation process to
patient/family as appropriate.
Rationale for Interventions
Explanation of the procedure to
those involved reduces anxiety and
reinforces information.
Evaluation of Goal on Day Care
Family states they understand
need for mechanical ventilation.
The patient’s sedation was
maintained to protect newly
placed tracheostomy.

Check that monitor alarms are set This action ensures client safety as Alarms were verified at the
appropriately at beginning of shift the nurse can provide immediate beginning of shift and were
and respond to them appropriately ventilation and oxygenation if promptly responded to.
necessary.

Patient will maintain a patent
tracheostomy and appropriate
sedation level this shift.
Monitor O2 saturation via arterial
line for continuous data and
provide supplementary oxygen
when indicated.
Secure the tracheostomy to the
patient with an appropriate device
to prevent dislodgment.
Monitoring the O2 saturation via
the arterial line will give the most
accurate, continuous data.
Securement is necessary to prevent
inadvertent extubation by the
patient.
The O2 saturation was maintained
above 94%. During sedation
vacation, patient’s O2 saturation
did not decrease and he was not
restless or agitated.
The securing device placement
was verified at the beginning of
shift and prior to any sedation
vacation.

Administer sedatives to maintain a Patients receiving mechanical The patient was receiving fentanyl
RAS score per provider’s orders to ventilation require sedation to and precedex to achieve sedation,
prevent dislodgment. decrease anxiety or pain associated but the fentanyl was discontinued.
with the intervention. With the fentanyl the patient’s
RAS was maintained at -1, while
not on a sedation vacation.

Assess patient response (i.e. Sedation vacations are shown to The patient would attempt to pull
agitation, anger) to tracheostomy decrease length of time requiring or touch his tracheostomy during
during sedation vacation. mechanical ventilation. Response sedation vacations. Physician
to ventilation should be assessed ordered to maintain sedation for
University of South Florida College of Nursing – Revision September 2014 20

Patient will be free from excessive
oropharyngeal secretions or
adventitious lung sounds this shift.
Provide suctioning of
tracheostomy 3 times during shift,
per physician order, or when
clinically indicated.
prior to discontinuing all methods this shift to protect newly place
of sedation. tracheostomy with weaning of
sedation to begin this evening.
Suctioning allows the nurse to Suctioning was performed when
remove secretions the clients is not ordered, as well as once during a
able to clear with cough. This sedation vacation when the patient
allows for normal exchange of gas. became restless due to inability to
clear the secretion with cough.

Drain collected fluid from This intervention reduces the Fluid was drained out of ventilator
condensation out of ventilator likelihood of the patient inhaling tubing once during shift.
tubing as needed. the water droplets that would
impair gas exchange.

Auscultate breath sounds for fluid
or secretions in the lungs that
could impair gas exchange.
Crackles or rhonchi suggest that
there is fluid or secretions in the
lungs that need to be suctioned.
Crackles were auscultated in all
lobes. Currently, the patient is on
furosemide to clear out excess
fluid. The healthcare team is
currently investigating alternative
methods to clear his lungs.

±2 DISCHARGE PLANNING:
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT: While discharge is not something we expect for this patient in the next week, he will likely need a consult from PT/OT as he has been on bed rest.
This increases the likelihood that his muscles have begun to atrophy and will need support to increase his activity level.
Pastoral Care
Durable Medical Needs: While discharge is not something we expect for this patient in the next week, there is a possibility that this tracheostomy may be
long term or permanent, depending on the damage to his lungs. Also, he will likely need assistive devices as he increases his activity level.
F/U appointments: Every patient should follow up with primary care and a specialists involved in their care.
Med Instruction/Prescription
Are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH: While discharge is not something we expect for this patient in the next week, he will likely need extensive rehab. He has suffered two cardiac
arrests, and has been reliant on mechanical ventilation. He will need assistance in his ADLs as he recovers.
Palliative Care

University of South Florida College of Nursing – Revision September 2014 21

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide to

planning care (10th ed.). Maryland Heights, MO: Mosby/Elsevier.

Bendersky, V.A., Mallipeddi, M. K., Perez, A., & Pappas, T. N. (2016). Necrotizing pancreatitis: challenges and

solutions. Clinical and Experimental Gastroenterology, 9, 345-350. doi: 10.2147/CEG.S99824

Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application

software]. Retrieved from http://itunes.apple.com

Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' Foundations of Psychiatric Mental Health

Nursing: A Clinical Approach (7th ed.). St. Louis, MO: Elsevier.

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical – Surgical Nursing: Preparation for

Practice (2nd ed.). New Jersey: Pearson Education.

University of South Florida College of Nursing – Revision September 2014 22