UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Lindsey Willis

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 10/29/15

Agency: TGH

1 PATIENT INFORMATION
Patient Initials: B.H.

Age: 29

Admission Date: 10/17/15

Gender: Female

Marital Status:

Primary Medical Diagnosis

Primary Language: English

Sickle Cell Crisis

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): N/A

N/A

Number/ages children/siblings: 2/12, 2/siblings

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

Code Status: Full Code

Living Arrangements: Lives with her mother in her house.

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

Culture/ Ethnicity /Nationality: African American

Religion: No Religious Affiliation

Type of Insurance: Medicaid

1 CHIEF COMPLAINT:
I was at the infusion center, and they were unable to control my pain. So I came to the hospital.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
29 y.o. female who presented to the E.D. with complaints of back pain, arthralgia, and myalgia. The patient has a history
of sickle cell anemia and reports this is typical of her crisis. Patient was told a few days ago by OSH that she was
pregnant. Patient reports that the pain is all over but worst in her anterior legs and lower back, aching/stabbing, 10/10.
She was seen at the infusion clinic, and reported no relief with the usual cocktail. She reports associated N/V, HA. Denies
vision change, CP, no SOB, no abdominal pain.
OLDCARTS: Pain Onset: 10/17/15; Location: generalized; Duration: constant; Characteristics: stabbing, aching;
Aggravating factors: too much stimulation; Relieving factors: pain medication; Treatment: pain medication, heat
application; Severity: 6/10

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
No Date
No Date
No Date

Operation or Illness
Blood transfusion
Abnormal pap smear: repeated and within normal limits
Pregnancy with prior complicated pregnancy: history of severe pre-eclampsia, delivered at 33 weeks

University of South Florida College of Nursing Revision September 2014

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Hypertension
Problems
Kidney

Gout
(angina, MI, DVT etc.)
Heart Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Anemia
Arthritis

Cause
of
Death
(if
applicab
le)

Environmental
Allergies

STD: history of chlamydia

Mental disorder: was on amitriptyline prior to pregnancy
Varicella
Thrombosis: during PICC line placement, treated with Coumadin and Lovenox
Post-partum depression: referred to social worker
UTI (lower urinary tract infection)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

No Date
No Date
No Date
No Date
2/2014
No Date

Father
Mother
Brother
Sister
Maternal
Grandmother
relationship
relationship

Comments: Unknown age of onsets

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (2013)
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
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

NO

Type of Reaction (describe explicitly)

Medications

Morphine
Potassium Sulfate

Anaphylactic shock
Facial edema

Other (food, tape,

latex, dye, etc.)

Adhesive
Latex
Oranges

Itching
Itching and rash
Uticaria, tachycardia, rash

University of South Florida College of Nursing Revision September 2014

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Sickle cell disease (SCD) is a genetically linked disorder resulting in abnormalities to the hemoglobin molecule of the red
blood cells (RBCs). It is most commonly seen in African Americans. SCD is seen in several forms: sickle cell anemia,
sickle cell thalassemia, or sickle cell hemoglobin (Hb) C. Sickle cell anemia, the severest of the disorders, is
homozygous and has no known cure. (Unbound Medicine, 2015) The trait is observed when a child inherits normal Hb
from one parent and Hb S (the abnormal Hb) from the other; individuals with the trait are carriers only and rarely
manifest signs of the disorder. (Unbound Medicine, 2015) RBCs that contain more Hb S than Hb A are susceptible to
sickling when exposed to decreased oxygen tension in the blood. (Unbound Medicine, 2015) Sickled RBCs are
inflexible, fragile, and rapidly destroyed by the spleen. Sickled RBCs have a decreased life span (30-40 days compared
120 days in normal RBCs), decreased oxygen-carrying capacity, and low Hb content. (Unbound Medicine, 2015)
Sickled RBCs do not flow easily through capillaries. Thus, RBCs easily clump together leading to obstruction within the
capillaries. Obstructions can lead to ischemia and necrosis, which produce the major clinical manifestations of pain.
(Unbound Medicine, 2015) On average, 50% of individuals with SCD do not survive past age 20, and most do not survive
past age 50. Complications of SCD include the following: chronic obstructive pulmonary disease, congestive heart
failure, and infarction of organs such as the spleen, retina, kidneys, and brain. (Unbound Medicine, 2015)

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation),
routine, and PRN medication. Give trade and generic name.]
Concentration
Name: Benadryl (diphenhydramine)
Dosage Amount: 25mg
Route: Intravenous
Frequency Every 6 hours PRN
Pharmaceutical class: H1 Antagonist
Home
Hospital or Both
Indication: Relief of allergic symptoms caused by histamine release
Adverse/ Side effects: Drowsiness, anorexia, dry mouth, hypotension.
Nursing considerations/ Patient Teaching: May cause drowsiness. Caution patient to avoid driving or other activities
requiring alertness until response to drug is known. Caution patient to avoid use of alcohol and other CNS
depressants concurrently with this medication.
Name: Lovenox

(enoxaparin)

Concentration: 40mg/1ml

Route: SQ

Dosage Amount: 40mg

Frequency: Twice

Pharmaceutical class: Antithrombotics,

daily

low molecular

Home
Hospital or Both
weight heparin
Indication: Prevention of venous thromboembolism and/or pulmonary embolism in surgical or medical
patients.
Adverse/ Side effects: Bleeding, anemia, dizziness, headache, hyperkalemia, edema.
Nursing considerations/ Patient Teaching: Assess for sign of bleeding and hemorrhage (bleeding gums; nosebleed;
unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP); bleeding from surgical site.
Notify health care professional if these occur. Advise patient to report any symptoms of unusual bleeding
or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health care professional
immediately.
Name: Folic

Concentration

Acid

Dosage Amount: 1mg

Route: Oral
Pharmaceutical class: Water
Indication: Prevention

Frequency: Daily

Soluble Vitamins

Home

Hospital

or

Both

and treatment of megaloblastic and macrocytic anemias.

Adverse/ Side effects: Rash, irritability, difficulty sleeping, malaise, confusion.
Nursing considerations/ Patient Teaching: Encourage patient to comply with diet recommendations of health care
professional. The best source of vitamins is a well-balanced diet with foods from the four basic food groups.
University of South Florida College of Nursing Revision September 2014
3

Assess patient for signs of megaloblastic anemia (fatigue, weakness, dyspnea) before and periodically
throughout therapy.
Name: Dilaudid

(hydromorphone)

Concentration

Dosage Amount: 2mg

Route: Intravenous

Frequency: Every

Pharmaceutical class: Opioid Agonists

Indication: Moderate

Home

Hospital

or

3 hours PRN
Both

to severe pain.

Adverse/ Side effects: Confusion,

sedation, hypotension, constipation.

Nursing considerations/ Patient Teaching: 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.
Initial drowsiness will diminish with continued use. Instruct patient on how and when to ask for pain
medication. Do not stop taking without discussing with health care professional; may cause withdrawal
symptoms if discontinued abruptly after prolonged use.
Name: Zofran

(ondansetron)
Concentration: 4mg/2ml
Dosage Amount: 4mg
Route: Intravenous
Frequency: Every 6 hours PRN
Home
Hospital or Both
Pharmaceutical class: HT 3 Antagonists
Indication: Prevention of nausea and vomiting.
Adverse/ Side effects: Torsade de pointes, headache, constipation, diarrhea.
Nursing considerations/ Patient Teaching: Monitor ECG in patients with hypokalemia, hypomagnesaemia, HF,
bradyarrhythmias, or patients taking concomitant medications that prolong the QT interval. Advise
patient to notify health care professional immediately if symptoms of irregular heart beat or involuntary
movement of eyes, face, or limbs occur.
Name: Jadenu

(deferasirox)

Concentration

Dosage Amount: 1,080mg

Frequency: Daily

Route: Oral
Pharmaceutical class: Chelating

Home Hospital or Both

agents
Indication: Chronic iron overload due to blood transfusions.
Adverse/ Side effects: GI bleeding/ulceration, hepatic failure, renal failure, erythema multiforme, Stevens-Johnson
syndrome.
Nursing considerations/ Patient Teaching: Assess patient for rash during therapy. Assess patient for GI pain and bleeding
during therapy; especially in patients receiving medications that increase risk of bleeding (NSAIDs,
corticosteroids, oral bisphosphonates, or anticoagulants. Advise patient to notify health care professional if
rash, stomach pain, bleeding, or changes in vison or hearing occur.
Name: Hydrea

(hydroxyurea)

Concentration

Dosage Amount: 1,500mg

Route: Oral

Frequency: Daily

Pharmaceutical class: Antimetabolites

Home

Hospital

or

Both

Indication: Reduction

of painful crises in sickle cell anemia and decreased need for transfusions in adult
patients with a history of recurrent moderate or severe crises.
Adverse/ Side effects: Anorexia, diarrhea, nausea, vomiting, leukopenia.
Nursing considerations/ Patient Teaching: Assess for signs of infection (fever, sore throat, cough, hoarseness, pain in
lower back or side, difficult or painful urination.) If these symptoms occur, notify health care professional
immediately. Instruct patient to take medication as directed, even if nausea, vomiting, or diarrhea is a
problem. Consult health care professional if vomiting occurs shortly after dose is taken.
Name: Norco

10-325 (hydrocodone
10mg-acetaminophen 325mg)

Concentration

Dosage Amount: 10mg-325mg

(1

tablet)

University of South Florida College of Nursing Revision September 2014

Route: Oral

Frequency: Every

Pharmaceutical class: Opioid Agonists

Home

Hospital

or

6 hours PRN
Both

Indication: Management

of moderate to severe pain.

dizziness, sedation, hypotension, constipation, dyspepsia, nausea.
Nursing considerations/ Patient Teaching: 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. Initial drowsiness will
diminish with continued use. Advise patient to take medication as directed and not to take more than the
recommended amount. Severe and permanent liver damage may result from prolonged use or high doses
of acetaminophen. Renal damage may occur with prolonged use of acetaminophen.
Adverse/ Side effects: Confusion,

Concentration
Contin (morphine)
Dosage Amount: 30mg
Route: Oral
Frequency: Twice Daily
Home Hospital or Both
Pharmaceutical class: Opioid Agonists
Indication: Severe pain.
Adverse/ Side effects: Respiratory depression, confusion, sedation, hypotension, constipation.
Nursing considerations/ Patient Teaching: 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. Initial drowsiness will
diminish with continued use. May cause drowsiness or dizziness. Caution patient to call for assistance
when ambulating or smoking and to avoid driving or other activities requiring alertness until response to
medication is known.
Name: MS

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Analysis of home diet
Diet patient follows at home?
My patients diet was high in vegetables, fruits, protein and
sodium, and lacked dairy. In comparison with an average
2,000 calorie diet, my patient was over her daily allowance
by 33 calories. She consumed a total of 347 empty calories.
The recommended daily allowance for grains is 6oz, and
my patient had consumed 4.5oz. Healthy examples of
whole-wheat grains include oatmeal, whole cornmeal, and
brown rice. The recommended daily allowance of
vegetables is 2.5 cups, and my patient had consumed 4
cups. Most vegetables are low in fat and calories, and most
any type can be eaten to reach your recommended daily
value. It is important to incorporate a variety of vegetables
into your diet: dark-green vegetables, starchy vegetables,
red and orange vegetables, and beans and peas. The
recommended daily allowance of fruits is 2 cups, and my
patient had consumed 5 cups. Like vegetables, most any
type of fruit can be eaten to reach your recommended daily
value, but it is important to avoid fruits in sugary syrups
and juices. The recommended daily allowance of dairy is 3
cups, and my patient consumed 0 cups. Healthy examples
of dairy include fat-free or low-fat milk, yogurt, and
cheese. The recommended daily allowance of protein is
5.5oz, and my patient consumed 8 oz. Healthy examples of
protein include lean or low-fat meat, poultry, or fish rich in
omega-3 fatty acids. The recommended daily allowance of
oils, saturated fats, and sodium are 6tsp, 22g, and 2,300mg,
respectively. My patient consumed 4 tsp. of oil, 15g of
saturated fat, and 3,285mg of sodium.
24 HR average home diet:
Breakfast: Biscuit with sausage and grits
Lunch: Chicken, green beans, and carrots
Dinner: Fried catfish, corn, peas, and peaches
Snacks: Bananas, an apple, and potato chips
Liquids (include alcohol): Apple juice, water, and soda (1
12oz can)

Use this link for the nutritional analysis by comparing

the patients 24 HR average home diet to the
recommended portions, and use My Plate as a
reference.

University of South Florida College of Nursing Revision September 2014

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
My mom.
How do you generally cope with stress? or What do you do when you are upset?
I listen to the music or clean.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Ive been a little stressed with my recent pregnancy.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? _No.____________________________________________________
Have you ever been talked down to? ___No._______ Have you ever been hit punched or slapped?
__No.__________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
___No._____________________________________ If yes, have you sought help for this? ___N/A_______________
Are you currently in a safe relationship?
Yes.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons
developmental stage for your
patients age group: 29 y.o.
My patient is in stage 6: intimacy vs. isolation. Erikson defined intimacy as the capacity to commit himself to concrete
affiliations and partnerships and to develop the ethical strength to abide by such commitments. Isolation is the avoidance
of intimacy. The task at this stage is to develop a commitment to work and relationships. Failure to do so will result in
impersonal relationships and difficulty with maintaining a job. (Treas & Wilkinson, 2014, pp. 164).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
I believe my patient has achieved intimacy as evidenced by her relationships with her significant other and her children.
Also, I believe she has become slightly isolated due to her illness, as she has to spend a large amount of time caring for
herself by attending chelation therapy and from her numerous hospitalizations.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life:
I think my patients disease has definitely affected her life and her ability to work and focus on her relationships. Due to
her illness my patient is unable to work and provide for her family. Also, she is unable to be the type of mother she desires
and take care of her children because of her disabling disease.

+3 CULTURAL ASSESSMENT:
University of South Florida College of Nursing Revision September 2014

What do you think is the cause of your illness?

Genetics.
What does your illness mean to you?
I sometimes feel limited and stuck in a bubble where I cant do what I want, and take care of my kids like I want."

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? _Yes.______________________________________________________________
Do you prefer women, men or both genders? __Men._____________________________________________________
Are you aware of ever having a sexually transmitted infection? _Yes.________________________________________
Have you or a partner ever had an abnormal pap smear? __Yes.____________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _No._____________________________________
Are you currently sexually active? __No.________________________ If yes, are you in a monogamous relationship?
____N/A________________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? __None.________________________________
How long have you been with your current partner? __Since high school. 13 years. _____________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _No.______________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
No.
__________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Im not
religious._________________________________________________________________________________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? N/A
How much?(specify daily amount)
N/A

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

thru

If applicable, when did the

patient quit? N/A

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? N/A

Has the patient ever tried to quit? N/A

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

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

Yes

No
For how many years? N/A
(age

thru

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

Is the patient currently using these drugs?

Yes No N/A

thru

If not, when did he/she quit?

N/A

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

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal
Integumentary

Changes in appearance of skin

Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen No

SPF:

Diverticulitis

Bathing routine: 2-3x/day

Other:
Be sure to answer the highlighted area
HEENT

Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds

Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:
Genitourinary

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 45x/day
Bladder or kidney infections

Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth

Nausea, vomiting, or diarrhea

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

Chills with severe shaking

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

Other:
Hematologic/Oncologic

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: B+
Other:
Metabolic/Endocrine

Diabetes

2x/day

Routine dentist visits

x/year

Immunologic

No

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Vision screening

Other:
Pulmonary

Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 2014
menstrual cycle
regular
irregular

Environmental allergies
last CXR? 6/28/15
Other:

menarche
age? 16
menopause
age? N/A
Date of last Mammogram &Result:

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

University of South Florida College of Nursing Revision September 2014

10

Cardiovascular

Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
3/5/15
Other:

N/A
Date of DEXA Bone Density &
MEN ONLY
Infection of male
genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

Mental Illness

Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal

Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases

Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

General Constitution

Recent weight loss or gain

How many lbs?
Time frame?
Intentional?
How do you view your overall health? Pretty healthy, but I have pain with my sickle cell disease.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No
Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision September 2014

11

10 PHYSICAL EXAMINATION:
General Survey: Patient
is a 29 y.o. female,
AOx4. Appears well
developed and well
nourished. No apparent
distress.
Temperature: 99.2F, oral

Height: 52
Pulse: 82
Respirations: 18

Weight: 184 lbs.

BMI: 32.6
Blood Pressure: 120/68, right arm

Pain: 6/10, generalized

SpO2: 97%

Is the patient on Room Air or O2:

Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
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

flat
loud

Central access device Type: Single lumen port Location: Right intra-clavicular fossa Date inserted: 10/17/15
Fluids infusing?
no
yes - what? .45% NaCl
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 / 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6-8 inches & left ear- 6-8 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: patient had original teeth, no dentures.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL: CL
LUL: CL
RML: CL
LLL: CL
RLL: CL

Chest expansion

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

University of South Florida College of Nursing Revision September 2014

12

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
No temporal or carotid bruits
Edema: +1
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: lower extremities, bilaterally
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 10/29/15 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Previous 24 hour output: not charted mLs

without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ RUE ___5____ LUE __5_____ RLE

or

with assistance

& __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
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Stereognosis, graphesthesia, and proprioception and DTR not assessed.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
WBC:
16.93 H
14.37 H
14.16 H
Normal: 4.6-10.2

Dates

Trend
The patients WBCs
remained elevated
throughout her hospital
stay, but did slightly
decrease overtime.

Analysis
WBCs exit in the blood
10/17/15
and help fight infection
10/24/15
within the body. Elevated
10/29/15
WBC levels is referred to
as leukocytosis and is a
response from the
immune system due to
University of South Florida College of Nursing Revision September 2014
13

Hemoglobin:
5.7 L
6.7 L
8.4 L

10/17/15
10/24/15
10/29/15

Normal: 12.2-16.2

Hematocrit:
16.0 L
19.0 L
24.2 L
Normal: 37.7-47

10/17/15
10/24/15
10/29/15

Platelets:
561 H
548 H
637 H
Normal: 142.0-424.0

The patients hematocrit

levels remained
decreased throughout her
hospital stay, but did
slightly increase
overtime.

10/17/15
10/24/15
10/29/15

The patients platelet

count remained elevated
and continued to elevate
throughout her hospital
stay.

10/17/15
10/24/15
10/29/15

The patients RBCs

remained decreased
throughout her hospital
stay, but did slightly
increase overtime.

RBC:
1.48 L
1.95 L
2.57 L
Normal: 4.04-5.48

The patients hemoglobin

levels remained
decreased throughout her
hospital stay, but did
slightly increase
overtime.

infection or disease. In
sickle cell anemia,
chronic neutrophilia is
often present with
leukocytosis.
Hemoglobin is the ironcontaining protein in
RBCs, that allow them to
bind oxygen and carry it
throughout the body.
Hemoglobin levels may
be decreased due to
excessive blood loss, iron
deficiency, bone marrow
disorders, or kidney
disease. In sickle cell
anemia, hemoglobin
levels are decreased due
to decreased RBCs.
Hematocrit levels are
often used to test for
anemia, polycythemia,
hydration status, and to
monitor therapy.
Decreased hematocrit
levels often indicate
anemia.
Platelets are fragments of
cells essential for normal
blood clotting. An
elevated platelet count is
referred to as
thrombocytosis and is
most often the result of an
existing condition. In
sickle cell anemia, spleen
function may be reduced;
leading to a reduction in
platelet destruction. Thus,
the number of platelets
are increased.
RBCs, which contain
hemoglobin, exist in the
blood to transport and
exchange oxygen to the
tissues. RBCs are
produced in the bone
marrow and released into
the bloodstream as they
mature. The average

University of South Florida College of Nursing Revision September 2014

14

Na+:
135
135
137
Normal: 135.0-148.0

10/17/15
10/23/15
10/27/15

The patients sodium

level remained within
normal limits throughout
her hospital stay.

10/17/15
10/23/15
10/27/15

The patients potassium

level remained within
normal limits throughout
her hospital stay.

K+:
3.6
3.7
3.7
Normal: 3.5-5.3

Cl-:
107
107
108 H
Normal: 98.0-107

10/17/15
10/23/15
10/27/15

HCO2:
22
23
24
Normal: 22.0-29.0

10/17/15
10/23/15
10/27/15

The patients chloride

level was within normal
limits in the beginning of
her hospital stay, but
became slightly elevated
overtime.

The patients bicarbonate

level remained within
normal limits throughout
her hospital.

lifespan of a RBC is 120

days. Chronic hemolytic
anemia leads to decreased
RBCs.
Sodium is an extracellular
cation, that is tested to
evaluate electrolyte
balance and hydration
levels. Hypernatremia is
most often due to
inadequate water intake
and dehydration.
Hyponatremia typically
due to excess sodium
loss, excess water intake
or retention, or edema.
Potassium is an
intracellular cation, that is
tested to evaluate fluid
and electrolyte balance.
Hyperkalemia is most
commonly due to kidney
disease. Hypokalemia
often occurs due to
electrolyte imbalance
from vomiting and
diarrhea.
Chloride is the most
abundant anion in the
extracellular fluid.
Chloride is tested to
evaluate electrolytes,
acid-base balance, and
hydration level.
Hyperchloremia typically
indicates dehydration.
Hypochloremia typically
occurs with disorders that
cause low sodium levels.
Bicarbonate is tested as
part of the electrolyte
panel to detect, monitor,
and evaluate electrolyte
imbalance. When
bicarbonate levels are
high or low, it indicates
the body is having trouble
maintaining acid-base
balance or something has
upset the electrolyte

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15

BUN:
8.0
8.0
7.0
Normal: 6.0-20.0

10/17/15
10/23/15
10/27/15

The patients BUN level

remained within normal
limits throughout her
hospital.

10/17/15
10/23/15
10/27/15

The patients creatinine

level remained within
normal limits throughout
her hospital.

Creatinine:
0.8
0.7
0.7
Normal: 0.57-1.11

imbalance. For example,

losing too much or
retaining too much fluid.
The blood urea nitrogen
test (BUN) is used to
measure kidney function.
Urea is a waste product
from the liver that results
from protein metabolism.
Urea travels in the blood
to the kidneys, where it is
filtered out of the blood
and eliminated in the
urine. BUN levels elevate
when there is disease or
damage to the kidneys.
Low BUN levels are less
common and are of
serious concern.
The creatinine test is used
to measure kidney
function. Creatinine is a
waste produced by
muscles from the
breakdown of creatinine.
Creatinine travels in the
blood to the kidneys,
where it is filtered out of
the blood and eliminated
in the urine. Creatinine
levels elevate due to
kidney disease or
conditions affecting
kidney function. Low
creatinine levels are less
common and are of
serious concern.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
Sickle Cell Crisis:
Manage persistent pain with analgesia. Pharmacologically managed with Dilaudid 2mg IV, given every 3
hours as needed.
Avoid hypoxia. Oxygen administration if patient becomes hypoxic or pulmonary symptoms are present.
Encourage the use of incentive spirometry, cough/deep breathing, promote safe activity/ambulation as
tolerated. Monitor for change in work of breathing, breath sounds, pleuritic chest pain, and presence of
cough. Transfusion of RBCs at 100ml/hr.
Maintain adequate fluid balance and avoid fluid excess. Continuous administration of 0.45% NaCl IV
University of South Florida College of Nursing Revision September 2014

16

infusion, given at 150ml/hr. Promote oral fluid intake. Closely monitor intake and output.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Acute pain r/t sickling of RBCs AEB patient states generalized pain.
2. Ineffective tissue perfusion r/t vaso-occlusive nature of sickled RBCs AEB generalized pain and edema in lower
extremities.
3. Risk for impaired gas exchange r/t decreased oxygen-carrying capacity of the blood.
4. Risk for infection r/t chronic disease and splenic malfunction.

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17

 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t sickling of RBCs AEB patient states generalized pain.
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will state pain at or below
*Administer analgesics as
Pharmacological interventions are The patient had pain medication
4/10 by the end of shift.
prescribed by physician (Ackley first-line approaches to the
administered throughout the shift
& Ladwig, 2014, pp. 581).
management of pain (Ackley &
and was frequently assessed for
Ladwig, 2014, pp. 581)
level of pain. Prior to
administration of pain medication,
patient reported pain as 7-8/10.
After administration of pain
medication, patient reported pain as
3-4/10.
Apply warm compress to the
Warmth causes vasodilation and
Patient was given warm
affected areas. (Vera, 2014)
increases circulation to hypoxic
compresses to help alleviate pain.
areas. (Vera, 2014)
Patients extremities/skin were
frequently assessed where heat was
applied.
*Teach and discuss alternative
Cognitive behavioral pain
Stress/pain reduction techniques
pain relief measures: relaxation
management may reduce reliance
were discussed with the patient on
techniques, biofeedback, yoga,
on pharmacological means of pain how they could help manage her
meditation, progressive relaxation
control. It also enhances the
patient. Patient appeared receptive
techniques, distraction techniques, patients sense of control. (Vera,
to information and willing to
guided imagery, and breathing
2014)
experiment with possible
techniques. (Vera, 2014)
stress/pain reduction techniques.
Provide support and carefully
This should be done to reduce
Patient was given additional
position affected extremities.
edema, discomfort, and risk of
pillows for elevation of extremities
(Vera, 2014)
injury, especially if osteomyelitis is and positioned in comfortable
present. (Vera, 2014)
position to help alleviate pain.
Ask the client to describe prior
Obtaining an individualized pain
I discussed with the patient her
experiences with pain,
history helps to identify potential
experience with pain and how she
effectiveness of pain management
factors that may influence the
currently manages her pain. The
interventions, responses to
clients willingness to report pain,
patient has thorough experience
analgesic medications including
as well as factors that may
with pain, she has suffered with
occurrence of side effects, and
influence pain intensity, the clients Sickle Cell Anemia since she was a
Patient Goals/Outcomes

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18

concerns about pain and its

treatment and informational needs
(Ackley & Ladwig, 2014, pp. 577)

response to pain, anxiety, and

pharmacokinetics of analgesics.
Pain management regimens must
be individualized to the client and
consider medical, psychological
and physical condition, age, level
of fear or anxiety, surgical
procedure, client goals and
preference, and previous response
to analgesics (Ackley & Ladwig,
2014, pp. 577)

child. Currently she uses pain

medication prescribed by her PCP,
as needed. She also applies heat to
the affected areas or takes warm
showers. Unless the patient is
experiencing sickle cell crisis, she
feels her pain is adequately
controlled.

Long term goal: Patient will have

better control of pain and have
no/fewer incidences of crisis
requiring hospitalization over the
next 6 months.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Nursing Diagnosis: Ineffective tissue perfusion r/t vaso-occlusive nature of sickled RBCs AEB generalized pain and edema in lower extremities.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate improved Monitor and note changes in level Changes observed may reflect
Patient remained alert and oriented,
tissue perfusion by the end of shift of consciousness, reports of
diminished perfusion to the central showed no signs of sensory and
AEB the following: vital signs
headache, dizziness, development
nervous system (CNS) due to
motor deficit, and no seizure
University of South Florida College of Nursing Revision September 2014
19

within normal limits for patient,

palpable peripheral pulses, urine
output at least 30 ml/hour, absence
of pain, usual mental status,
capillary refill less than 3 seconds,
skin warm and dry, absence of
paresthesias.

of sensory and motor deficits

(hemiparesis or paralysis), and
seizure activity. (Vera, 2014)

ischemia or infarction. Stagnant

cells must be mobilized
immediately to prevent further
ischemia/infarction. (Vera, 2014)

activity. Denied headache and

dizziness.

Carefully monitor vital signs:

Assess pulse points for rate,
rhythm, and volume. Take note of
hypotension, rapid, weak, and
thready pulses, and increased or
shallow respirations. (Vera, 2014)

Accumulation and sickling in

peripheral vessels may lead to
complete or partial blockage of a
vessel with diminished perfusion to
surrounding tissues. Sudden
massive splenic sequestration of
dead cells can lead to shock.
(Vera, 2014)
Dehydration causes increase in
sickling and occlusion of
capillaries other than hypovolemia
or decrease in blood volume.
Decrease renal perfusion may
indicate vascular occlusion. (Vera,
2014)
Occlusion of blood vessels and
circulatory stasis may lead to
edema of extremities, potentiating
risk of tissue ischemia and
necrosis. Note: Assess for edema in
the genitals of men including
priapism. (Vera, 2014)
Sickling of blood can cause
reduced peripheral circulation and
often leads to dermal changes and
delayed healing. (Vera, 2014)
Changes may reflect increased
sickling of cells and diminished
circulation where organs are further
involved. Watch out for these signs

Patients vital signs remained

within normal limits: 3+ peripheral
pulses, R=17 with normal depth,
BP=112/59.

Maintain adequate fluid intake

and monitor urine output. (Vera,
2014)

Assess client for edema. (Vera,

2014)

Assess the lower extremities for

skin texture and ulcerations.
(Vera, 2014)
Note reports of change in
character of pain, or development
of bone pain, angina, tingling of
extremities, eye pain and

University of South Florida College of Nursing Revision September 2014

Patient was on continuous 0.45%

NaCl IV therapy and oral hydration
was promoted. Patient maintained
adequate urine output throughout
shift: minimum of 30 ml/hour.
Patient had mild edema in the
lower extremities. Edema was nonpitting.

Patients skin texture was dry and

shiny but remained the same
throughout the shift. Patient had no
ulcerations.
Patient denied any change in
characteristics of pain. Denied no
new development of pain or
tingling of extremities.
20

disturbances in vision. (Vera,

2014)

and symptoms as they may indicate

MI, pulmonary infarction, or
occlusion of vasculature of the
eye. (Vera, 2014)

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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21

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, MO: Elsevier.
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia,
PA: F.A. Davis Company.
Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software].
Retrieved from http://itunes.apple.com
USDA: United States Department of Agriculture. (2015). Choose MyPlate. Retrieved from
http://www.choosemyplate.gov/about
Vera, M. (2014). 6 Sickle Cell Anemia Nursing Care Plans - Nurseslabs. Retrieved from
http://nurseslabs.com/6-sickle-cell-anemia-crisis-nursing-care-plans/

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