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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Melissa Lopez
Assignment Date: 2/14/17
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: SMH
 1 PATIENT INFORMATION
Patient Initials: MM Age: 59 Admission Date: 2/11/17
Gender: Male Marital Status: Married Primary Medical Diagnosis: Diverticulitis of colon
with perforation
Primary Language: Gurati Other Medical Diagnoses: (new on this admission)
Level of Education: Bachelor’s Degree Perforation of colon
Occupation: Manager of computer network storage company

Number/ages children/siblings: Four children, ages 27, 25, 21, 18


One brother, 67 years old Code Status: “Never been asked” – full code
Served/Veteran: No Advanced Directives: No
If yes: Ever deployed? N/A If no, do they want to fill them out? No
Living Arrangements: Lives in Orlando in a two-story house with Surgery Date: None Procedure: N/A
his wife, 92-year-old mother, and 21-year-old daughter

Culture/ Ethnicity /Nationality: English (Indian descent) Type of Insurance: Blue Cross
Religion: Muslim

 1 CHIEF COMPLAINT:
Patient laughed and said, “Pain! Pain in the abdomen and rectum.”

 3 HISTORY OF PRESENT ILLNESS:


Patient was admitted to the ER 2/11/2017 with severe abdominal and rectal pain, which began the day before at 3:30pm
according to the patient. The patient was driving from Orlando to Sarasota for a beach vacation when the pain began in
the pelvic area and then generalized throughout the abdomen, which he rated as a 10 on a 0-10 scale at its worst. The
patient described the pain as stabbing, constant “no matter what I did. I couldn’t lie anywhere, since I was in the car.” The
patient described slight fever and chills at the onset of the pain, but denied nausea, vomiting, or fever at the ER. A CT
scan was performed and revealed an abnormal pneumoperitoneum, small bubbles throughout the abdomen and pelvis, as
well as abnormal inflammatory changes around the mid sigmoid with multiple diverticula, but no abscess noted. The
patient was treated for pain and is currently in 6 East Tower, receiving IV antibiotics and fluids continuously. The patient
currently reports pain around a 4 on a 0-10 scale.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY


Date Operation or Illness
3 weeks ago Small episode of diverticulitis; patient went to his doctor and received oral antibiotics which seemed
to resolve his symptoms
April 2015 Knee surgery to repair a torn meniscus from playing soccer
University of South Florida College of Nursing – Revision September 2014 1
2008 Hospitalized for diverticulitis for 4 days; patient was given antibiotics and was sent home

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)
FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause

Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Double
Father 54
pneumonia
Mother 92 N/A
Brother 67 N/A
Sister
relationship

relationship

relationship

Comments:

Mother developed glaucoma 40 years ago, dementia 6-8 months ago, and arthritis 2 years ago.
Father developed diabetes after the patient was born, per the patient.
Brother is a surgeon, so the patient is not aware of any of his medical problems.

 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 (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
In 2008 patient traveled to Saudi, and stated he “got everything –
meningitis, Hepatitis B, tetanus” and did not list any more.

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Reaction occurred at 5 years old; but has tolerated amoxicillin in the past

Medications

Other (food, tape, None


latex, dye, etc.)
University of South Florida College of Nursing – Revision September 2014 2
 5 PATHOPHYSIOLOGY:
Diverticulitis is a condition in which diverticula (herniations or pockets in the gastrointestinal tract) become inflamed.
Specifically, diverticula consist of outpouchings of the mucosa and submucosa through the muscle layers, most commonly
seen in the wall of the sigmoid colon (Huether & McCance, 2012). It is understood that increases in intraluminal pressure,
especially in weakened areas of the colon wall such as where arteries penetrate the tunica muscularis, cause the formation
of diverticula, though the exact etiology is unknown. Thickening of the circular muscles and shortening of the teniae coli
which surround the diverticula, which is associated with increased collagen and elastin deposition, are commonly found in
those with diverticulosis. The law of Laplace, which states that wall pressure increases as the diameter of a cylinder
decreases, has been associated with diverticular disease in the past. It has been noted that habitual low residue diets, such
as those high in refined foods, reduce fecal bulk, which then reduces the diameter of the colon (Huether & McCance,
2012). According to Laplace’s law, therefore, a low residue diet may contribute to the increase in pressure involved in
diverticula formation. Another theory is that altered neuromuscular activity in the colon is the cause of diverticular disease
(Hinchey , Schaal , & Richards , 1978). If the diverticula rupture from the increase in pressure, this causes inflammation,
and diverticulosis (asymptomatic diverticular disease), becomes diverticulitis. Bacterial and local ischemia may also play
a role in diverticular inflammation. Symptoms of diverticulitis include lower abdominal pain, fever, leukocytosis, and
tenderness of the left lower quadrant. A colonoscopy is a common diagnostic method for diverticulitis, and treatment
includes nonabsorbable antibiotics, bowel rest, and pain management if there are no complications. One rare complication
of diverticulitis is perforation of the bowel, which can progress to fecal peritonitis and death if not treated. Symptoms of a
perforated bowel include severe abdominal pain, chills, fever, nausea, and vomiting (Lal, 2016). Surgery may be required
if the perforation is severe. The preferred operation to treat a bowel perforation is primary resection of the diseased bowel
with or without anastomosis, though treatment should address the individual needs of the patient, including the extent of
his or her disease, the expertise of the surgeon, and the resources available for the patient’s post-operative care (Hinchey ,
Schaal , & Richards , 1978).

 5 MEDICATIONS:
Name Enoxaparin (Lovenox) Concentration 30 mg Dosage Amount 30 mg injection

Route Subcutaneous Frequency Q12H


Pharmaceutical class antithrombotics; low molecular weight heparins Home Hospital or Both
Indication DVT prophylaxis
Adverse/ Side effects
CNS: dizziness, headache, insomnia
CV: edema
GI: constipation, ↑ liver enzymes, nausea, vomiting
GU: urinary retention
Derm: alopecia, ecchymoses, pruritus, rash, urticaria
F and E: hyperkalemia
Hemat: bleeding, anemia, eosinophilia, thrombocytopenia
Local: erythema at injection site, hematoma, irritation, pain
MS: osteoporosis
Misc: fever
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-
positive stools); bleeding from surgical site. Notify health care professional if these occur.
Contraindicated in:
 Hypersensitivity
 Hypersensitivity to benzyl alcohol (multidose vial)
 Positive in vitro test for antiplatelet antibody in the presence of enoxaparin
 Active, major bleeding.
Use Cautiously in:
 Severe hepatic or renal disease (adjust dose if CCr <30 mL/min)
 Retinopathy (hypertensive or diabetic)
 Uncontrolled hypertension
 Recent history of ulcer disease
 History of congenital or acquired bleeding disorder
 Women <45 kg and men <57 kg (↑ exposure to enoxaparin with ↑ risk of bleeding; weight-adjusted dosing recommended)
 Malignancy
University of South Florida College of Nursing – Revision September 2014 3
Exercise Extreme Caution in:
 Severe uncontrolled hypertension
 Bacterial endocarditis
 Bleeding disorders
 GI bleeding/ulceration/pathology
 Hemorrhagic stroke
 Recent CNS or ophthalmologic surgery
 History of thrombocytopenia related to heparin
 Spinal/epidural anesthesia or spinal puncture (↑ risk of spinal/epidural hematoma that may lead to long-term or permanent paralysis).

Patient Teaching
 Instruct patient in correct technique for self-injection, care, and disposal of equipment.
 Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care
professional immediately.
 Instruct patient not to take aspirin, naproxen, or ibuprofen without consulting health care professional while on enoxaparin therapy.

(Up-to-Date Drug Information, 2017)

Name Famotidine (Pepsid) Concentration 20 mg (1 tab) Dosage Amount 20 mg (1 tab)

Route PO Frequency BID


Pharmaceutical class histamine h2 antagonists Home Hospital or Both
Indication Abdominal irritation/pain
Adverse/ Side effects
CNS: confusion, dizziness, drowsiness, hallucinations, headache
CV: ARRHYTHMIAS
GI: constipation, diarrhea, nausea
GU: ↓ sperm count, erectile dysfunction
Endo: gynecomastia
Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia
Local: pain at IM site
Misc: hypersensivity reactions
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.
 Monitor CBC with differential periodically during therapy.
 PO: Administer with meals or immediately afterward and at bedtime to prolong effect.
Contraindicated in:
 Hypersensitivity
 Phenylketonuria (chewable tablets only)
Use Cautiously in:
 Renal impairment (more susceptible to adverse CNS reactions; ↑ dosage interval recommended if CCr <10 mL/min)
 Pedi: Injection contains benzyl alcohol which has been associated with gasping syndrome in neonates
 Geri: More susceptible to adverse CNS reactions; dose ↓ recommended.

Patient Teaching
 Instruct patient to take medication as directed for the full course of therapy, even if feeling better. Take missed doses as soon as remembered but not if almost
time for next dose. Do not double doses.
 Advise patients taking OTC preparations not to take the maximum dose continuously for more than 2 wk without consulting health care professional. Notify
health care professional if difficulty swallowing occurs or abdominal pain persists.
 Inform patient that smoking interferes with the action of histamine antagonists. Encourage patient to quit smoking or at least not to smoke after last dose of the
day.
 May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to the drug is known.
 Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.
 Inform patient that increased fluid and fiber intake and exercise may minimize constipation.
 Advise patient to report onset of black, tarry stools; fever; sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional
promptly.

(Up-to-Date Drug Information, 2017)

Name Piperacillin/Tazobactum (Zosyn) Concentration 3.375 mg/100 ml NS over 60 min Dosage Amount 3.375 mg

Route IVPB Frequency Q6H


Pharmaceutical class extended spectrum penicillins Home Hospital or Both
Indication Patients with CRCL greater than 40 ml/min
Adverse/ Side effects
CNS: SEIZURES (HIGHER DOSES), confusion, dizziness, headache, insomnia, lethargy

University of South Florida College of Nursing – Revision September 2014 4


GI: CLOSTRIDIUM DIFFICILE-ASSOCIATED DIARRHEA (CDAD), diarrhea, constipation, drug-induced hepatitis, nausea, vomiting
GU: interstitial nephritis
Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rashes (↑ in cystic fibrosis patients), urticaria
Hemat: bleeding, leukopenia, neutropenia, thrombocytopenia
Local: pain, phlebitis at IV site
Misc: HYPERSENSITIVITY REACTIONS, INCLUDING ANAPHYLAXIS AND SERUM SICKNESS, fever (↑ in cystic fibrosis patients), superinfection
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional
immediately if these occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
 Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of
Clostridium difficile-associated diarrhea (CDAD). May begin up to several weeks following cessation of therapy.
 Assess for skin reactions (rash, fever, edema, mucosal erosions or ulcerations, red or inflamed eyes). Monitor patient with mild to moderate rash for
progression. If rash becomes severe or systemic symptoms occur, discontinue piperacillin/tazobactam.
Contraindicated in:
 Hypersensitivity to penicillins, beta-lactams, cephalosporins, or tazobactam (cross-sensitivity may occur).
Use Cautiously in:
 Renal impairment (dosage reduction or increased interval recommended if CCr <40 mL/min);
 Sodium restriction

Patient Teaching
 Advise patient to report rash and signs of superinfection (black furry overgrowth on tongue, vaginal itching or discharge, loose or foul-smelling stools) and
allergy.
 Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat
diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.

(Up-to-Date Drug Information, 2017)

Name Hydromorphone Concentration 0.5 mg/ml Dosage Amount 0.5 mg injection

Route IV Frequency Q2H PRN


Pharmaceutical class opioid agonists Home Hospital or Both
Indication severe pain
Adverse/ Side effects
CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams
EENT: blurred vision, diplopia, miosis
Resp: RESPIRATORY DEPRESSION
CV: hypotension, bradycardia
GI: constipation, dry mouth, nausea, vomiting
GU: urinary retention
Derm: flushing, sweating
Misc: physical dependence, psychological dependence, tolerance
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be
decreased by 25–50%. Initial drowsiness will diminish with continued use. Geri: Pedi: Assess geriatric and pediatric patients frequently; more sensitive to the
effects of opioid analgesics and may experience side effects and respiratory complications more frequently.
 Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects.
Administer stimulant laxatives routinely if opioid use exceeds 2–3 days, unless contraindicated.
 Pain: Assess type, location, and intensity of pain prior to and 1 hr following IM or PO and 5 min (peak) following IV administration. When titrating opioid
doses, increases of 25–50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or
the patient reports satisfactory pain relief. When titrating doses of short-acting hydromorphone, a repeat dose can be safely administered at the time of the peak
if previous dose is ineffective and side effects are minimal.
 Assess risk for opioid addiction, abuse, or misuse prior to administration. Abuse or misuse of extended-release preparations by crushing, chewing, snorting, or
injecting dissolved product will result in uncontrolled delivery of hydromorphone and can result in overdose and death.
Contraindicated in:
 Hypersensitivity;
 Some products contain bisulfites and should be avoided in patients with known hypersensitivity;
 Severe respiratory depression (in absence of resuscitative equipment) (extended-release only);
 Acute or severe bronchial asthma (extended-release only);
 Paralytic ileus (extended-release only);
 Acute, mild, intermittent, or postoperative pain (extended-release only);
 Prior GI surgery or narrowing of GI tract (extended-release only);
 Opioid non-tolerant patients (extended-release only);
 Severe hepatic impairment (extended-release only)
Use Cautiously in:
 Head trauma;
 ↑ intracranial pressure;

University of South Florida College of Nursing – Revision September 2014 5


 Severe pulmonary disease;
 Moderate or severe renal disease (extended-release only) (dose ↓ recommended)
 Moderate hepatic impairment (extended-release only) (dose ↓ recommended)
 Hypothyroidism;
 Seizure disorder;
 Adrenal insufficiency;
 Alcoholism;
 Undiagnosed abdominal pain;
 Prostatic hypertrophy;
 Biliary tract disease (including pancreatitis);

Patient Teaching
 Instruct patient on how and when to ask for pain medication. Do not stop taking without discussing with health care professional; my cause withdrawal
symptoms if discontinued abruptly after prolonged use.
 Advise patient that hydromorphone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it
was prescribed.
 May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
 Advise patient to notify health care professional if pain control is not adequate or if side effects occur.
 Advise patient to change positions slowly to minimize orthostatic hypotension.
 Instruct patient to avoid concurrent use of alcohol or other CNS depressants.
 Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional
before taking any new medications.
 Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
 Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.

(Up-to-Date Drug Information, 2017)

Name Oxycodone (Tylenol/Percocet) Concentration 5 mg/APAP Dosage Amount 325mg (1 tab)

Route PO Frequency Q4H


Pharmaceutical class opioid agonists Home Hospital or Both
Indication moderate pain
Adverse/ Side effects
CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams
EENT: blurred vision, diplopia, miosis
Resp: RESPIRATORY DEPRESSION
CV: orthostatic hypotension
GI: constipation, dry mouth, choking, GI obstruction, nausea, vomiting
GU: urinary retention
Derm: flushing, sweating
Misc: physical dependence, psychological dependence, tolerance
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Assess type, location, and intensity of pain prior to and 1 hr (peak) after administration. When titrating opioid doses, increases of 25–50% should be
administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analog scale or the patient reports satisfactory pain relief.
A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.
 Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation
may be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use.
 Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most
patients who receive oxycodone for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term
therapy.
 Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk, and laxatives to minimize
constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2–3 days, unless contraindicated.
 Assess risk for opioid addiction, abuse, or misuse prior to administration. Abuse or misuse of extended-release preparations by crushing, chewing, snorting, or
injecting dissolved product will result in uncontrolled delivery of oxycodone and can result in overdose and death.
Contraindicated in:
 Hypersensitivity;
 Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance or hypersensitivity;
 Significant respiratory depression;
 Paralytic ileus;
 Acute or severe bronchial asthma;
 Acute, mild, intermittent, or postoperative pain (extended-release).
Use Cautiously in:
 Head trauma;
 ↑ intracranial pressure;
 Severe renal or hepatic disease;
 Hypothyroidism;
 Adrenal insufficiency;
University of South Florida College of Nursing – Revision September 2014 6
 Alcoholism;
 Seizure disorders;
 Undiagnosed abdominal pain;
 Prostatic hyperplasia;
 Difficulty swallowing or GI disorders that may predispose patient to obstruction (↑ risk for GI obstruction);

Patient Teaching
 Instruct patient on how and when to ask for and take pain medication.
 Advise patient that oxycodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was
prescribed.
 Medication may cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving and other
activities requiring alertness until response to medication is known.
 Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool.
 Advise patient to make position changes slowly to minimize orthostatic hypotension.
 Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication.
 Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional
before taking any new medications.
 Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
 Advise patient to notify health care professional if pregnancy is planned or suspected, or if breast feeding.

(Up-to-Date Drug Information, 2017)

Name Dextrose 5% / NS with KCl Concentration 150 ml/hr Dosage Amount 20 mEq KCl/1000 ml

Route IV Frequency continuous


Pharmaceutical class carbohydrates Home Hospital or Both
Indication NPO diet
Adverse/ Side effects
Endo: inappropriate insulin secretion (long-term use)
F and E: fluid overload, hypokalemia, hypomagnesemia, hypophosphatemia
Local: local pain/irritation at IV site (hypertonic solution)
Metabolic: glycosuria, hyperglycemia
* CAPITALS indicate life-threatening.
Italics indicate most frequent.
Nursing considerations
 Assess the hydration status of patients receiving IV dextrose. Monitor intake and output and electrolyte concentrations. Assess patient for dehydration or
edema.
 Assess nutritional status, function of gastrointestinal tract, and caloric needs of patient.
 Diabetic patients and patients receiving hypertonic dextrose solution (>5%) should have serum glucose, potassium, and phosphate monitored regularly.
 Monitor IV site frequently for phlebitis and infection.
Contraindicated in:
 Allergy to corn or corn products
 Hypertonic solution (>5%) should not be given to patients with CNS bleeding or anuria or who are at risk of dehydration.
Use Cautiously in:
 Known diabetic patients (frequent lab assessment necessary to quantitate appropriate doses)
 Neonates (excess/rapid infusion of solutions >10% may ↑ risk of intracerebral hemorrhage)
 Chronic alcoholics or severely malnourished patients (administration requires initial pretreatment with thiamine).

Patient Teaching
 Explain the purpose of dextrose administration to patient.
 Instruct diabetic patient on the correct method for self–blood glucose monitoring.
 Advise patient on when and how to administer dextrose products for hypoglycemia.

(Up-to-Date Drug Information, 2017)

University of South Florida College of Nursing – Revision September 2014 7


 5 NUTRITION:
Diet ordered in hospital? Full liquid Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
My analysis of Mr. MM’s diet is that he is generally very
Breakfast: cup of black tea with milk (sometimes 1 spoon well rounded with his nutritional choices. However, it does
of sugar) seem that he eats more than his body requires, which he
admits to. I would recommend eating less refined grains,
Lunch: egg, cheese, tomato sandwich with some chips more vegetables, and more whole fruit rather than fruit
(white, fresh bread from Publix) juice because of the high sugar content without the
necessary fiber content. Because of his diagnosis of
Dinner: fish, veggies, rice (or lamb, chicken) diverticulitis, I would be very cautious eating foods high in
insoluble fiber until his inflammation subsides, when the
Snacks: mostly cut out snacks in the last 6 months; infection is resolved by the antibiotics. Therefore, I would
sometimes dried fruits, nuts, chips avoid whole grains for now out of deference to foods high
in soluble fiber, such as whole fruits. Fruit is ideal for his
Liquids (include alcohol): 2 cups of tea, water, green tea, condition because it provides plenty of glucose, vitamins,
juices, no alcohol and a gentle balance of soluble and insoluble fiber. As a
Muslim, this recommendation should not cause any
problems, as fruit is not prohibited in his diet. He is
currently on a full liquid diet slowly transitioning into solid
food, so I would recommend fresh tomato soup, possibly
with a cup of fruit on the side to start out.

1 COPING ASSESSMENT/SUPPORT SYSTEM:


Who helps you when you are ill? Patient replied, “My wife.”

How do you generally cope with stress? or What do you do when you are upset?
Patient reported, “Badly. I lose my temper, then calm down, and sort things out, figure out what I have to do.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient said none of these were applicable to him.

+2 DOMESTIC VIOLENCE ASSESSMENT


Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”

University of South Florida College of Nursing – Revision September 2014 8


Have you ever felt unsafe in a close relationship? Patient said, “No.”

Have you ever been talked down to? Patient said, “No.” Have you ever been hit punched or slapped? Patient said, “No.”

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? Patient said,
“No.” If yes, have you sought help for this? N/A ________

Are you currently in a safe relationship? Patient said, “Yes. I love my wife.”

 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 (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
The definition of “generativity” according to Miriam-Webster’s Medical Dictionary is, “a concern for people besides
self and family that usually develops during middle age; especially: a need to nurture and guide younger people and
contribute to the next generation” (Generativity, 2017).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Mr. MM is in the “generativity” stage of Erikson’s stages of psychosocial development. The patient is in his late 50’s,
and though he is married, has four children with one still living at home, is still working, he showed great interest in my
education and enjoyed talking with me. He also enjoyed explaining his views on culture and his religion to me and his
nurse, exhibiting the desire to teach the next generation.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Mr. MM’s condition may impact his quality of life, and therefore his ability to reach out into younger people’s lives. If
not treated properly, he would not be able to help others very much because of the need to attend to his own needs, which
in his condition would be having to manage his pain and constipation.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
The patient replied, “over-eating, gluttony, an absolutely pathetic lifestyle. I’m a work-a-holic, and have a weakness of
not being able to learn how to relax.”

What does your illness mean to you?


The patient stated that his illness meant “a change in lifestyle, a reality check, a plea of help to change the things that need
to change.”

+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? Patient replied, “Yes.” ________________________________________________
Do you prefer women, men or both genders? Patient replied, “Women,” and gestured to his wife. ______________
Are you aware of ever having a sexually transmitted infection? Patient replied, “No.” __________________________
Have you or a partner ever had an abnormal pap smear? Patient replied, “No.”_______________________________
Have you or your partner received the Gardasil (HPV) vaccination? Patient replied, “No.”________________________

Are you currently sexually active? Patient replied, “Yes.”___________________________


University of South Florida College of Nursing – Revision September 2014 9
If yes, are you in a monogamous relationship? Patient replied, “Yes.”_______________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Patient replied, “None.” He implied that having only one wife was his protection. _

How long have you been with your current partner? Patient replied, “Thirty-five years.” ________________________

Have any medical or surgical conditions changed your ability to have sexual activity? Patient replied, “No.”___________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient replied, “No.”

University of South Florida College of Nursing – Revision September 2014 10


±1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life?
Patient replied, “My religion is a total way of life, and therefore, it holds a tremendous bearing for my personality, actions, and
behavior.”______________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Patient replied, “My religion forbids gluttony and overeating, so I feel I am not as religious as I should be,” and laughed while
looking at his wife._______________________________________________________________________________________
______________________________________________________________________________________________________

+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? How much? (specify daily amount) For how many years? 31 years
Cigarettes 40 per day (age 17 thru 48 )

If applicable, when did the


Pack Years: 62
patient quit? 11 years ago

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Did not ask

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? N/A How much? N/A For how many years?
Volume: (age thru )
Frequency: Patient said, “Never.”
If applicable, when did the patient quit?
N/A

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

Is the patient currently using these drugs?


If not, when did he/she quit?
Yes No
N/A

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient replied, “No.”

5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing – Revision September 2014 11


 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Chills with severe shaking (with
Nausea, vomiting, or diarrhea
diverticulitis)
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever (with diverticulitis)
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 yes SPF: 50 Diverticulitis Life threatening allergic reaction
Bathing routine: shower 2 times a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? (4/2015)
HEENT Other: Hematologic/Oncologic
Difficulty seeing (Glasses; far-sighted) Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing (Left ear) dysuria Bruises easily
Ear infections (Left ear) hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 3 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1 x/day Diabetes Type:
Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
Vision screening (1 x a year) Intolerance to hot or cold
Other: Osteoporosis
Other:
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? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis (as a child, 4 years old)
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression (during 1999-2000)
Hyperlipidemia Frequency of prostate exam? 1x/yr Schizophrenia
Chest pain / Angina Date of last prostate exam? 1/2017 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures (torn meniscus) Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2/13 Arthritis Chicken Pox
University of South Florida College of Nursing – Revision September 2014 12
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? Gained 5 lbs, lost 6 lbs
Time frame? Last 6 months
Intentional? Yes
How do you view your overall health? Patient replied, “Not ill, but I’m not happy with my health. I want to be fitter.”

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient replied, “No.”

Any other questions or comments that your patient would like you to know?
Patient replied, “No.”

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


±10 PHYSICAL EXAMINATION:
General Survey: Height: 5’ 6” Weight: 216 lbs 14 oz BMI: Pain: (include rating and
Pulse: 78 Blood Pressure: (include location) location) 3-4 on a 0-10 scale
Respirations: 14 135/86 Left Brachial Artery in abdomen
Temperature: (route SpO2: 98 Is the patient on Room Air or O2
taken?) 97.9 oral
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
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
Patient had dark spots on his pelvic, pubic, and lower back regions. He said he thought they might have resulted from an
allergic reaction to shrimp. The spots were originally raised and filled with clear fluid, but then healed into dark spots.

Peripheral IV site Type: 20 gauge Location: Left AC joint Date inserted: 2/13/2017
no redness, edema, or discharge
Fluids infusing? no yes – what? 5% Dextrose with KCl 20 mEq/1000 mL; NS with Zosyn IVPB
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: palpable submandibular lymph nodes; discharge for 32 years in left ear, perforated, finally has appointment with
doctor in April – amount of discharge 8 on a 0-10 scale – keeps it clean, keeps it covered when showering or swimming – hot
environment, tiredness, and stress aggravate it

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: all fields clear, no adventitious breath sounds
RUL: CL LUL: CL
RML: CL LLL: CL
RLL: CL

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

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


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

N/A

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

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly


Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 2 / 14 / 2017 ) 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 – Describe:

GU Urine output: Clear Cloudy Color: dull yellow/straw Previous 24 hour output: 700 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness – patient declined

Musculoskeletal: Full ROM intact in all extremities without crepitus


Strength bilaterally equal at __5____ RUE ___5___ LUE ___5___ RLE & __5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative (not assessed)
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: X Achilles: Ankle clonus: positive negative Babinski: positive negative

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


±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS:
Lab Dates Trend Analysis
WBC [4.5-11.0 10x3/ul] The patient’s WBC’s The patient arrived at the ER with
were high on symptoms of infection, which is
15.0 (H) 2/11/17 admission, but confirmed by his elevated WBC’s.
12.0 (H) 2/12/17 decreased daily until The fact that they returned to normal
10.2 2/13/17 they returned to normal range indicates that the infection has
range on the day of his subsided, the antibiotics have taken
discharge. affect, and he is ready for discharge.
Hemoglobin [14.0-17.5 g/dL] The patient’s The patient was not experiencing any
hemoglobin was within blood loss upon admission, so a
14.3 2/11/17 normal limits upon normal hemoglobin would be
12.1 (L) 2/12/17 admission, but expected unless there was an
12.0 (L) 2/13/17 decreased significantly underlying condition. However,
the next day, followed sustained inflammation may cause
by a slight decrease on hemoglobin to lower, which was the
the day of his case with the patient as he was
discharge. receiving treatment. With treatment,
inflammation is expected to decrease,
which is confirmed by the minimal
drop in hemoglobin the next day. The
collective drop in hemoglobin is not
significant enough to cause alarm, as
he showed no symptoms of anemia.
Hematocrit [40.0-52.0%] The patient’s Because hematocrit is the ratio of
hematocrit was within RBC’s to the total volume of blood,
42.5 2/11/17 normal limits upon the analysis will be similar to that of
36.6 (L) 2/12/17 admission, but hemoglobin, which is a protein that
36.0 (L) 2/13/17 decreased more notably carries oxygen in RBC’s, unless an
the next day, followed underlying condition exists, which is
by a slight decrease on not indicated in this patient. The
the day of his patient shows no signs of anemia,
discharge. and the trends are to be expected
considering the patient’s condition
and treatment.
Glucose Serum [60-100mg/dL] The patient had The patient’s blood glucose is
consistently high blood consistently higher than what is
102 (H) 2/11/17 glucose levels considered normal range, which is
139 (H) 2/12/17 throughout his stay, not necessarily related to his
122 (H) 2/13/17 with the highest being diagnosis, but may affect his health
on the second day of later on. His numbers may indicate
hospitalization. prediabetes, though he would need
further testing for a more accurate
portrayal of his glucose absorption.
His levels are also most likely
affected by the time at which his
blood glucose was tested and when
he had eaten last.

University of South Florida College of Nursing – Revision September 2014 16


CT of Abdomen &Pelvis with Abnormal Acute sigmoid diverticulitis with
IV Contrast 2/11/17 inflammatory changes perforation with pneumoperitoneum,
most prominently no abscess
surrounding the
sigmoid colon
Stationary ECG Study Intervals
Rate: 87 Sinus rhythm
2/12/17 PR: 138 (No previous ECG available for
QRSD: 86 comparison)
QT: 348
QTc: 419

Axis
P: 36
QRS: 1
T: -4

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:


The patient is currently on a full liquid diet, slowly introducing solid food. He is being treated with IV antibiotics
by the nurse. He is scheduled for a consult with Infectious Disease to determine the need for a PICC line for
continued out-patient IV antibiotics which the doctor prefers, as opposed to oral antibiotics which would be more
convenient for the patent since he is on vacation here from Orlando.

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


1. Acute pain related to inflammation of bowel as evidenced by diagnosis of diverticulitis

2. Risk for vascular trauma as evidenced by infusion of antibiotics

3. Deficient knowledge related to diet needed to control disease as evidenced by acute inflammation of the bowel

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


± 15 CARE PLAN
Nursing Diagnosis: Acute pain related to inflammation of bowel as evidenced by diagnosis of diverticulitis
Patient Nursing Interventions to Achieve Goal Rationale for Interventions Evaluation of Goal on Day
Goals/Outcomes Provide References Care is Provided
Client will use a  Determine if the client is  Determining location, temporal aspects,  The patient self-
self-report pain experiencing pain at the time of pain intensity, characteristics and the reported his pain level
tool to identify the initial interview. If pain is impact of pain on function and quality of and the nurse
current pain level present, conduct and document a life are critical to determine the administered pain
and establish a comprehensive pain assessment underlying cause of pain and medication
comfort-function and implement pain management effectiveness of treatment. This initial accordingly. The
goal. interventions to achieve comfort. assessment includes all pain information comfort-function goal
Components of this initial that the client can provide and provides was established to
assessment include: location, data for the development of the keep his pain from
quality, onset/duration, temporal individualized pain management plan. increasing throughout
profile, intensity, aggravating and Self-report is considered the single most his hospitalization.
alleviating factors, and effects of reliable indicator of pain presence and  The patient was able
pain on function and quality of intensity (Ackley & Ladwig, 2011). to self-report his pain
life.  The first step in pain assessment is to using the 0-10 pain
 Assess pain level in a client using determine if the client can provide a self- scale, identifying his
a valid and reliable self-report pain report. Single-dimension pain ratings are pain as a 4.
tool, such as the 0-10 numerical valid and reliable as measures of pain  The patient was
pain scale. intensity level (Ackley & Ladwig, 2011). assessed
 Assess the client for pain presence  Pain assessment is as important as approximately every
routinely at frequent intervals, physiological vital signs and pain is hour for pain,
often at the same time as vital considered as the “fifth vital sign.” Acute particularly after his
signs are taken, and during activity pain should be reliably assessed both at pain medication was
and rest. Also assess for pain with rest (important for comfort) and during given, and did not
interventions or procedures likely movement (important for function and report an increase in
to cause pain. decreased client risk of cardiopulmonary pain other than when I
and thromboembolic events (Ackley & was palpating his
Ladwig, 2011). abdomen, which
subsided as soon as I
stopped.
Client will report  Ask the client to describe prior  Obtaining an individualized pain history  The client was not
that pain experiences with pain, helps to identify potential factors that assessed for pain
University of South Florida College of Nursing – Revision September 2014 18
management effectiveness of pain management may influence the client’s willingness to management history at
regimen achieves interventions, responses to report pain, as well as, factors that may this time.
comfort-function analgesic medications including influence pain intensity, the client’s  The patient desired no
goal without occurrence of adverse effects, and response to pain, anxiety, and more than a 4 on the
adverse effects. concerns about pain and its pharmacokinetics of analgesics. Pain 0-10 pain scale. The
treatment and informational needs. management regimes must be patient was able to
* individualized to the client and consider ambulate and shower
 Ask the client to identify a medical, physiological, and physical without difficulty or
comfort-function goal, a pain condition; age, level of fear or anxiety; pain.
level, on a self-report pain tool, surgical procedure; client goals and
that will allow the client to preference; and previous response to
perform necessary or desired analgesics (Ackley & Ladwig, 2011).
activities easily.  The relationship between pain level and
functional goals should be a major focus
of the development of individualized
pain management plans. Effective pain
relief with function such as mobilization,
couching, and deep breathing is critical
for decreasing risk factors for
cardiopulmonary and thromboembolic
complications after surgery (Ackley &
Ladwig, 2011).
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
 are any of the patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH

University of South Florida College of Nursing – Revision September 2014 19


Palliative Care
 Reinforce the importance of taking pain medications to maintain the comfort-function goal.
 Demonstrate the use of appropriate nonpharmacological approaches in addition to pharmacological approaches for helping to control pain,
such as application of heat and/or cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music listening, and
television watching.

Nursing Diagnosis: Risk for vascular trauma as evidenced by infusion of antibiotics


Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Goal on Day Care
Achieve Goal Provide References is Provided
Client will remain free from  Verify objective and  Verify if client will remain  Infectious Disease was
vascular trauma during the time of estimate duration of hospitalized during the scheduled to determine
hospitalization. treatment. Check whole treatment or will go whether the patient would
physician’s order. home with the device need a PICC line or oral
(Ackley & Ladwig, 2011). antibiotics.
The client will maintain skin  Assess client’s clinical  Consider possible clinical  The patient did not have
integrity, tissue perfusion, usual situation when venous conditions that cause any contraindications or
tissue temperature, color and infusion is indicated. changes in temperature, comorbidities that would
pigment during hospitalization. color and sensitivity of the influence IV insertion.
possible venous access site
(Ackley & Ladwig, 2011).
The client will state site is  Monitor catheter-skin  The infusion should be  The IV site was assessed,
comfortable during junction and surrounding discontinued at the first and there were no
hospitalization. tissues at regular intervals, sign of infiltration or abnormalities noted. The
observing possible extravasation (Ackley & patient verbalized no
appearance of burning, Ladwig, 2011). tenderness upon palpation,
pain, erythema, altered and no discomfort. The
local temperature, catheter was kept in place
infiltration, extravasation, and the continuous infusion

University of South Florida College of Nursing – Revision September 2014 20


edema, secretion, of antibiotics was
tenderness or induration. * maintained.
±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 patient’s medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
The patient is scheduled for a consult with Infectious Disease in order to determine which route of antibiotics therapy should be used, IV via PICC
line in out-patient visits or oral antibiotics. The doctor will discharge him once this route is determined, and the patient plans to return home with
his wife where he will follow up with his doctor and fulfill his prescriptions for antibiotics as determined.
 Select with the client, the insertion site most compatible with the development of activities of daily living (if the PICC line is indicated).
 Avoid the use of the dominant hands as an IV placement site.

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


References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: an evidence-based guide to planning care
(9th ed.). St. Louis: Elsevier Inc.
Generativity. (2017). Retrieved from Miriam-Webster : https://www.merriam-webster.com/medical/generativity
Hinchey , E., Schaal , P., & Richards , G. (1978). Treatment of perforated diverticular disease of the colon.
Retrieved from PubMed.gov: https://www.ncbi.nlm.nih.gov/pubmed/735943
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis: Elsevier Inc.hhh
Lal, S. K. (2016, 5 11). Gastrointestinal perforation. Retrieved from MedlinePlus:
https://medlineplus.gov/ency/article/000235.htm
Up-to-date drug information. (2017). Retrieved from Davis'sDrugGuide.com: http://www.drugguide.com/ddo

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