UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Anjouli Marie Gerez

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 11/22/2015

Agency: Bayfront Medical Center

Patient Initials: N.G.

Age: 66 years old

Admission Date: 10/12/2015

Gender: Male

Marital Status: Married

Primary Medical Diagnosis:

Right-sided Weakness (ICD-10 code: I69.051)

Primary Language: English

Level of Education: High School

Other Medical Diagnoses:

Hemorrhagic Stroke (ICD-10 code: I63.9)

Occupation (if retired, what from?): Retired Courier of AMPM Courier

Services Incorporated
Number/ages children/siblings:

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

Code Status: Full Code

Living Arrangements: Four bedroom house with no stairs

Advanced Directives: No
If no, do they want to fill them out? Yes
Surgery Date: Not Applicable
Procedure: Not Applicable

Culture/ Ethnicity /Nationality: Jamaican

Religion: Seventh Day Adventist

Type of Insurance: None private pay only

1 CHIEF COMPLAINT:
I was feeling good in the morning and I took a nap. I woke up and my wife noticed that I was not talking clearly. I cannot
be understood clearly and she called 911 and the ambulance took me to the ER.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
This patient is a male who is 66 years of age. He was brought in by the ambulance to the Bayfront Medical Center (BMC)
emergency department on Monday, 10/12/2015. The patient mentioned that he attended to his morning routine of a full
breakfast and a morning walk on Monday, 10/12/2015. He decided to take a nap after lunch. The wife of the patient
noticed that he had a right facial droop, right sided weakness, and slurred speech after the patient woke up from his nap.
She also added that these symptoms started at around 1345 on Monday, 10/12/2015. Therefore, she called 911 and the
patient was taken to the emergency department in BMC. The patient also mentioned that he and his wife did not try any
treatment to treat for the facial droop, weakness, and slurred speech because his wife immediately called 911. A
Computerized Tomography (CT) scan of the brain was performed while he was in the emergency department and it
showed an acute parenchymal hemorrhage centered in the left basal ganglia. A chest x-ray was also performed in the
emergency department which showed a cardiomegaly. Lastly, a carotid ultrasound was also performed which showed no
significant common or internal carotid artery stenosis. The patient was seen by a neurologist at the emergency department
but he was initially admitted to the Neurology Intensive Care Unit (NICU) for further evaluation and management. While
in the NICU, neurologic assessments were done every two hours and nicardipine (Cardene) drip, a calcium channel

University of South Florida College of Nursing Revision September 2014

blocker, was administered to keep his systolic blood pressure below 150 mm Hg. The patient was transferred to the
neurology medical unit as his critical symptoms were managed and he is working with a physical therapist to regain his
strength back. The patient mentioned that he is hoping to continue physical therapy at a rehabilitation facility that he can
afford to pay with private pay.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

Father

85

Mother

92

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

Gout

(angina,
MI, DVT
etc.)
Heart
Trouble

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable)
Prostate
Cancer
Heart
Condition

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Hypertension - lisinopril

Age (in years)

2013

Brother
Sister
Comments:
Patient states, I have five sisters and four brothers. They are all in good health in the Caribbean."

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service (Not Applicable)
Adult Diphtheria
Adult Tetanus (1965; not given within ten years)
Influenza (flu)
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications

NAME of
Causative Agent
None

YES

NO

Type of Reaction (describe explicitly)

Not Applicable

University of South Florida College of Nursing Revision September 2014

None

Not Applicable

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Hemorrhagic stroke is the third most common cause of cerebrovascular accident and it accounts for approximately 15
percent of all strokes. It results from bleeding in the brain tissue itself or into the subarachnoid space (Lewis, Dirksen,
Heitkemper, Bucher, & Camera, 2011). The common causes of a hemorrhagic stroke are hypertension, ruptured aneurysm
or vascular malformation, bleeding into a tumor, medications such as anticoagulants, head trauma, and illicit drug use. In
addition, it is more common in older adults and younger age groups who are involved in motor vehicle crashes, assaults,
and falls (Osborn, Wraa, Watson, & Holleran, 2014). However, hypertension is the primary cause of a hemorrhagic
stroke. Hypertension involves primary smaller arteries and arterioles that results in the thickening of the vessel walls and
possible necrosis. The small aneurysms in these smaller vessels or arteriolar necrosis in the brain may precipitate the
bleeding. A mass of blood is formed into the brain tissue and the adjacent brain tissue may be deformed, compressed, and
displaced. Therefore, it produces ischemia, edema, and increased intracranial pressure (Huether & McCance, 2012). The
most common areas for a hemorrhagic stroke are the putamen and surrounding internal capsule. It may also occur in the
thalamus, cerebellum, brainstem, and the white matter of the frontal temporal, and parietal lobes (Osborn et al., 2014).
The most common clinical manifestations of a hemorrhagic stroke include severe headache, weakness or numbness on
either side of the body, difficulty with speech or understanding speech, visual disturbances, gait problems, and balance
problems (Osborn et al., 2014). Diagnostic studies are done to confirm that it is a hemorrhagic stroke and not a brain
lesion such as a subdural hematoma. The most important diagnostic tool is the non-contrast computed tomography (CT)
scan because it can help distinguish between an ischemic and hemorrhagic stroke. The CT scan will help determine the
size and location of the stroke. In addition, serial CT scans are used to assess whether the treatment is effective and to
evaluate recovery (Lewis et al., 2011). On the other hand, a CT angiography (CTA) provides visualization of the cerebral
blood vessels and it can be performed after or at the same time as the non-contrast CTA. The CTA will help estimate
cerebral perfusion and detect filling defects in the cerebral arteries. A Magnetic Resonance Imaging (MRI) is also used to
determine the stage of the brain injury and it can detect vascular lesions and blockages but a Magnetic Resonance
Angiography may be used to detect vascular lesions and damages similar with a CTA (Lewis et al., 2011).
The prognosis of a patient who has a hemorrhagic stroke is poor and the 30-day mortality rate is 40 percent to 80 percent.
Fifty percent of the deaths also occur within the first 48 hours (Lewis et al., 2011). However, treatment of a hemorrhagic
stroke depends on its location but it is focused on stopping or reducing the bleeding, controlling the increased intracranial
pressure, preventing another bleed, and preventing vasospasm (Huether & McCance, 2012). Anticoagulants and platelet
inhibitors are contraindicated with patients with hemorrhagic stroke. However, oral and intravenous (IV) agents like
calcium channel blockers and vasodilators may be used to maintain blood pressure within a normal to high-normal range
of possibly a systolic blood pressure less than 160 mm Hg (Lewis et al., 2011). In addition, medications and blood
products may be administered to correct abnormal clotting (Osborn et al., 2014). The patient was admitted with
symptoms of right-sided weakness, right facial droop, and slurred speech with a possible stroke due to the history of
hypertension. It was diagnosed through a collection of medical and family history as well as a CT scan, chest x-ray,
carotid ultrasound, and an MRI. The patient was treated with nicardipine (Cardene) drip, a calcium channel blocker, to
keep his systolic blood pressure below 150 mm Hg and neurological assessments were performed every two hours.

University of South Florida College of Nursing Revision September 2014

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

Concentration

Dosage Amount 5 mg

Route Oral

Frequency One time daily

Pharmaceutical class ACE Inhibitor

Home

Hospital

or

Both

Indication Management of hypertension

Side Effects: Cough, dizziness, hypotension
Adverse Effects: Angioedema, hyperkalemia
Nursing Considerations: Assess patient for signs of angioedema (dyspnea, facial swelling); Monitor blood pressure and pulse; Monitor potassium for hyperkalemia;
Monitor BUN and serum creatinine for renal function.
Patient Teaching: Teach patient to rise or change positions slowly to minimize orthostatic hypotension; Warn patient about persistent cough that may not subside until
medication is discontinued; Instruct patient to notify health care provider if rash, swelling of hands or feet, swelling of face, or difficulty swallowing occurs.
Name acetaminophen (Tylenol)

Concentration

Dosage Amount 650 mg

Route Oral

Frequency every 4 hours, PRN (as needed)

Pharmaceutical class Antipyretics

Home

Hospital

or

Both

Indication Treatment of mild pain, fever, or a temperature over 101 F

Side effects: Renal failure, neutropenia, pancytopenia
Adverse Effects: Hepatotoxicity, Stevens-Johnson Syndrome
Nursing considerations: Assess alcohol usage; Assess type, location, and intensity of pain; Assess signs of fever
Patient Teaching: Advise patient to take medication exactly as directed; Avoid alcohol; Teach patient not to take more than four grams every 24 hours and be aware of
medications with acetaminophen mix.
Name hydralazine (Apresoline)

Concentration

Dosage Amount 10 mg

Route Oral

Frequency Every six hours interval, PRN (as needed)

Pharmaceutical class Vasodilator

Home

Hospital

or

Both

Indication Management of moderate to severe hypertension and systemic blood pressure over 150 mm Hg
Side effects: Headache, anorexia, nausea, vomiting, diarrhea, muscle cramps, tachycardia
Adverse effects: Severe orthostatic hypotension, skin flushing, severe headache
Nursing considerations: Obtain blood pressure and pulse before each dose; Monitor blood pressure.
Patient Teaching: Rise slowly from lying to sitting position to minimize orthostatic hypotension; Assess feet and ankles for fluid retention.

Name magnesium hydroxide (Milk of Magnesia)

Concentration

Route Oral

Dosage Amount 30 mL
Frequency One Time Daily, PRN (as needed)

Pharmaceutical class Laxative

Home

Hospital

or

Both

Indication Treatment of indigestion and constipation

Side effects: Diarrhea, hypotension, nausea, vomiting, respiratory depression
Nursing considerations: Assess patient for abdominal distention, presence of bowel sounds, and pattern of bowel function.
Patient Teaching: Teach patient that it is only a short term therapy not for a long-term therapy.
Name ondansetron (Zofran)

Concentration

Route Intravenous Push

Dosage Amount 4 mg
Frequency every 4 hour interval, PRN (as needed)

Pharmaceutical class Five HT3 Antagonist

Home

Hospital

or

Both

Indication Prevention of nausea and vomiting

Side effects: Headache, constipation, diarrhea, drowsiness, fatigue, weakness
Adverse effects: Torsades de Pointes on echocardiogram (ECG)
Nursing considerations: Assess patient for nausea, vomiting, abdominal distention, and bowel sounds; Monitor ECG
Patient teaching: Notify health care provider for symptoms of irregular heart beat or involuntary movement of eyes, face, and limbs.

Name nicardipine (Cardene)

Route Intravenous

Concentration

Dosage Amount 40 mg
Frequency Continuous

University of South Florida College of Nursing Revision September 2014

Pharmaceutical class Calcium Channel Blocker

Home

Hospital

or

Both

Indication Management of hypertension and for systolic blood pressure of >150

Side effects: Peripheral edema, bradycardia, hypotension, tachycardia
Adverse effects: Arrhythmias, heart failure, Stevens-Johnson syndrome
Nursing considerations: Monitory blood pressure and pulse prior, during dose therapy, and throughout therapy. Monitor ECG periodically; Monitor intake and output
ratios and daily weight; Assess for signs of heart failure like peripheral edema, rales or crackles, and weight gain.
Patient Teaching: Advise patient to avoid grapefruit juice; Teach patient to notify health care provider for symptoms of dyspnea, swelling of hands and feet, or
hypotension.

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? Mechanical Soft Food
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: One banana, One cup of rice porridge, One tuna
salad sandwich
Lunch: One cup of rice, Two pieces of small baked chicken
breast
Dinner: One piece of small baked chicken breast, One cup
of rice, one cup of raw spinach, one piece of baked potato
Snacks: One cup of papaya pieces, one cup of watermelon
pieces
Liquids (include alcohol): One cup hot chocolate, seven
glasses of water (approximately 56 oz. of water)

The graph shows that the patient is lacking some of the

food groups. According to USDA (n.d.), the patient is
over his limits of grains, fruits, and protein; however,
the patient is under his limit of vegetables and dairy.
The patient needs to eat more of a daily balanced diet
and keep in mind of his daily calorie limit of possibly
two thousand. He needs to add three-fourth cups of
vegetables to his diet and he needs to add two and a
half cups of dairy to his diet. On the other hand, he
needs to limit his intake of grains to six ounces, fruits
to two cups, and protein to five and a half ounces. It
may also be recommended for him to follow a DASH
diet that consists of a low sodium diet since he has a
history of hypertension. The patient may also see a
dietitian to help with his diet.

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?
The wife of the patient helps him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient states, I read religious books and most especially, the bible when I feel stressed.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient denies feelings of depression, anxiety, and being overwhelmed with relationships, friends, or social life.

+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? Patient states, Sometimes but I do not feel emotional about it.____
Have you ever been hit punched or slapped? Patient states, I was punched when I was a teenager for personal reasons but
not recently.
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? _Not Applicable
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

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry vs.
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:

Eriksons stage eight of psychosocial development is ego integrity versus despair which is applicable for individuals
over the age of 65 years old. This stage is about the acceptance of ones life, worth, and eventual death. Ego integrity
shows a satisfaction with life and an understanding of the place of a person in the life cycle. Meanwhile, despair is a
sense of discomfort with life and aging, loss, and fear of death (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient is undergoing Eriksons psychosocial development of despair because the patient made a statement about
his illness and he stated that, It means a lot because I do not know if I will come back around and what will happen to
me. In addition, the patient had a flat affect and he was speaking at a slow rate while answering questions related to his
illness.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The development of hemorrhagic stroke due to the history of hypertension led this patient to Eriksons stage eight of
psychosocial development of despair because the patient stated that, My health right now may be the cause of my death
and I do not know if I will make it to my next birthday.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states, I have no idea and I do not know how it started. It is just all in my brain.

University of South Florida College of Nursing Revision September 2014

What does your illness mean to you?

Patient states, It means a lot because I do not know if I will come back around and what will happen to me.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?_Yes_____________________
Do you prefer women, men or both genders? _Women__________________________
Are you aware of ever having a sexually transmitted infection? __No_______________
Have you or a partner ever had an abnormal pap smear?__No________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No________________
Are you currently sexually active? __Yes_________ If yes, are you in a monogamous relationship?_Yes__________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Patient states, I do not use anything because we are faithful with each other.
How long have you been with your current partner?_21 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?
__Patient states, My religion is a big part of my life and my whole life is wrapped around it. I am one of the elders at our church.
____________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__ Patient states, I do not believe that my religion influences my current condition.___________________________________
______________________________________________________________________________________________________

+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?
How much?(specify daily amount)

Yes
No
For how many years? years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

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

Yes

No
For how many years?
(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient denies exposure to any occupational or environmental hazards or risks.
5. For Veterans: Have you had any kind of service related exposure?
Not applicable

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: one to two times a day
Other: Patient denies use of sunscreen.

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2x/day
Routine dentist visits
Vision screening

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? none
Other:

Chills with severe shaking

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

Genitourinary

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

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 4-5x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
1x/year

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis

Other: Patient states, I had nosebleeds

when I was a teenager. I also had my tooth
remove recently.

Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 10/12/2015
Other: Patient states, I feel like I want to
cough.

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam? 2x/year
Date of last prostate exam? 07/10/2015
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness

Childhood Diseases
Measles

University of South Florida College of Nursing Revision September 2014

Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?10/12/2015
Other:

Pain
Gout
Osteomyelitis
Arthritis
Other: Patient states, I have not had any
fractures but I was in a car accident
before.

Mumps
Polio
Scarlet Fever
Chicken Pox
Other: Patient states, I had measles as a
child in 1950.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient denies seeking any medical attention with anyone.
Any other questions or comments that your patient would like you to know?
Patient does not have any questions or comment that he would like to know.

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is a Height: 72 inches
Weight: 102.27 kg
Pain: (include rating & location)
66 year old male, obese, and
BMI: 30.5 (Obese)
0
well kept. He is cooperative
and does not show any visible
signs of distress. He is awake,
alert, and oriented times three
to person, place, and time. He Pulse: 74 bpm
Blood Pressure: (include location)
has right side weakness and
146/88 right upper arm
right facial droop.
Temperature: (route taken?) Respirations: 16
98.3 F - Oral
SpO2 : 98%
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
Comments: Patient is clean, hair is combed, and dresses appropriately for setting and temperature. He tries to maintain eye
contact every now and then. He has right sided weakness and right facial droop.
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
Comments: Patient mumbles during our conversation.
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
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
Comments: Skin is normal to ethnicity.

talkative
withdrawn

Peripheral IV site Type: 20 gauge

Location: Right hand
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Comments: Saline locked
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 10/18/2015

Date inserted:
Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 15 inches & left ear- 15 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions

University of South Florida College of Nursing Revision September 2014

Dentition: Patient has a complete set of teeth without dentures.

Comments: Patient has a narrow peripheral vision and it is not in the normal range of a normal range of peripheral vision
assessment. Patient has an intact EOM without nystagmus towards his right side. The patient was not able to follow proper
commands in assessing the EOM towards his left side.
Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
Comments: Patient does not have any sputum production. Patient states, I feel
like I want to cough.
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds: S1 S2 Regular
Irregular

PMI felt at: Midline, fifth intercostal space

No murmurs, clicks, or adventitious heart sounds

No JVD

Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
The lead II on this ECG six second strip shows a normal sinus rhythm with depressed T wave. The depressed T wave may
be an indication of a cardiac ischemia due to his history of hypertension and recent cerebral hemorrhage.

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: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds hypoactive 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
Urine output:
Clear
Cloudy
Color: Yellow
Previous 24 hour output: 700 mLs
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 14 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

University of South Florida College of Nursing Revision September 2014

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __1_ RUE ___5_ LUE ___1_ 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
Comments: Patient has passive ROM on the RUE and RLE without crepitus. Patient has active ROM on the LUE and LLE
without crepitus.
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Comments: CN I (Olfactory), II (Optic), V (Trigeminal), VII (Facial), VIII (Vestibulocochlear), X (Vagus), XI (Accessory),
XII (Hypoglossal) are intact. CN III, IV, VI (Oculomotor) - Patient has an intact EOM without nystagmus towards his right
side. The patient was not able to follow proper commands in assessing the EOM towards his left side. CN IX
(Glossopharyngeal) Patient has difficulty sticking tongue out. Stereognosis, graphesthesia, and proprioception are not
intact on his right hand and intact on his left hand. Rombergs test and gait were not assessed because patient does not have
the strength to stand up and his RLE is weak. DTR and Babinski reflex were not assessed because a knee reflex hammer
was not available during the time of assessment.

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):

University of South Florida College of Nursing Revision September 2014

Lab
White Blood Count (WBC)
Normal (4.5-11)

Dates

6.6

(10/13/2015)

7.7

(10/14/2015)

6.8

(10/16/2015)

Red Blood Count (RBC)

Normal (5.21-5.81)
4.27 (L)

(10/13/2015)

4.55 (L)

(10/14/2015)

4.33 (L)

(10/16/2015)

Hemoglobin
Normal (13.2-17.3 g/dL)
12.6 (L)

(10/13/2015)

13.2 (L)

(10/14/2015)

12.7 (L)

(10/16/2015)

Hematocrit
Normal (40.7-50.3%)
37.8 (L)

(10/13/2015)

39.9 (L)

(10/14/2015)

38.0 (L)

(10/16/2015)

Platelet
Normal (150,000 400,000
microL)
(10/13/2015)
187
(10/14/2015)
185
(10/16/2015)
177

Trend
On admission, the patient
has a WBC within the
normal range. The WBC
trend continues to be
within the normal range
that shows that the patient
is not fighting off any
infection or
inflammation.

Analysis
WBC evaluates viral and
bacterial infections. A
WBC within the normal
range shows that the
patient does not have any
infection or
inflammation.

On admission, the patient

has a low RBC that
shows he has a disease
process going through his
body. The RBC trend
remains low after one day
indicating that the disease
process continues.

RBC evaluates the

number of circulating
RBC in the blood towards
diagnosing a disease. A
decreased RBC shows a
continuing disease
process due to the
hemorrhage in his brain.

On admission, the patient

has decreased
hemoglobin that shows he
has a disease process
going through his body.
The hemoglobin trend
remains low after one day
indicating that the disease
process continues.
On admission, the patient
has decreased hematocrit
that shows he has a
disease process going
through his body. The
hematocrit trend remains
low after one day
indicating that the disease
process continues.
On admission, the patient
has a platelet that is
within the normal range
which shows that he does
not have any active
bleeding or any blood
disorders. The platelet
trend continues to be
within the normal range
that shows that the patient

Hemoglobin verifies the

conditions involving the
RBC. A low hemoglobin
shows a continuing
disease process possibly
due to to the hemorrhage
in his brain.
Hematocrit measures the
percentage of the volume
of whole blood. A low
hematocrit shows a
continuing disease
process possibly due to
the hemorrhage in his
brain.
Platelet assists in
diagnosing and
evaluating treatment for
blood disorders. A
platelet count that is
within the normal range
shows that she does not
have any active bleeding
or other blood disorders.

University of South Florida College of Nursing Revision September 2014

Sodium
Normal (135-145mEq/L)
139

(10/13/2015)

138

(10/14/2015)

136

(10/16/2015)

Potassium
Normal (3.5-5.3mEq/L)
3.9

(10/13/2015)

4.2

(10/14/2015)

4.1

(10/16/2015)

Chloride
Normal (97-107 mEq/L)
107

(10/13/2015)

107

(10/14/2015)

106

(10/16/2015)

Blood Urea Nitrogen (BUN)

Normal (8-21 mg/dL)
10

(10/13/2015)

11

(10/14/2015)

10

(10/16/2015)

does not have any active

bleeding or other blood
disorders.
On admission, the patient
has a sodium that is
within the normal range.
The sodium trend
continues to be within the
normal range that shows
that the patient has an
acceptable electrolyte
balance and hydration
levels.
On admission, the patient
has a potassium within
the normal range. The
potassium trend remains
in the normal range
indicating that the patient
is not having any chronic
disorders or fluid
problems.

On admission, the patient

has a chloride within the
normal range. The
chloride trend remains in
the normal range
indicating that the patient
is not having any acidbase balance and
hydration levels problem.
On admission, the patient
has a BUN that is within
normal range. The BUN
trend remains within the
normal range indicating
that the patient is not
having any kidney
problems.

Sodium is used to assess

electrolyte balance
related to various
disorders. A sodium that
is within normal range
shows that the patient has
an acceptable electrolyte
balance and hydration
levels. Also, it shows that
he does not have any
disorders like diarrhea
and vomiting.
Potassium is used to
assess electrolyte balance
related to various
disorders and fluid
balance. A potassium
within normal range
shows that this patient
may not have a chronic
disorder and excessive
fluid. The imbalance may
have been corrected
through the body or the
prescribed medications.
Chloride is used to
evaluate electrolytes and
hydration level. A
chloride within normal
range shows that the
patient does not have any
acid-base balance or
hydration levels
problems. It also shows
that he does not have any
type of acidosis.
BUN is used to assist in
assessing for renal
function toward diagnosis
disorders such as kidney
failure. This is a test to
measure the amount of
urea nitrogen in the
blood. A BUN within the
normal range indicates
that the patient is not

University of South Florida College of Nursing Revision September 2014

Creatinine
Normal (0.61-1.21 mg/dL)
0.9

(10/13/2015)

0.7

(10/14/2015)

0.9
GFR non-African American
Normal (60 or more)

(10/16/2015)

>60

(10/13/2015)

>60

(10/14/2015)

>60

(10/16/2015)

Creatinine Kinase Myocardial Band

(CK MB)
Normal (4-6)
4.1

(10/12/2015)

Troponin I
Normal (less than 4.8 ng/mL)
0.01

(10/12/2015)

No acute pulmonary process.

Cardiomegaly.

(10/12/2015)

Chest X-ray

On admission, the patient

has a creatinine within
the normal range. The
creatinine trend remains
within the normal range
indicating that the patient
is not having any renal
problems.
On admission, the patient
has a GFR within the
normal range. The GFR
trend remains within the
normal range indicating
that the patient is not
having any renal
problems.
On admission, the patient
has a CK MB within the
normal range. This
indicates that the patient
does not have a possible
myocardial infarction or
any disorders related to
the musculoskeletal
system.

On admission, the patient

has a Troponin I within
the normal range. This
indicated that the patient
is not having any
myocardial muscle
damage related to
myocardial infarction.
On admission, the chest
x-ray showed no signs of
acute pulmonary process.
However, it showed that
there is cardiomegaly.
This indicates that the
patient may have a
cardiovascular disorder.

having any kidney

problems.
Creatinine is used to
assess kidney function
found in acute renal
failure. A creatinine
within the normal range
shows that the patient is
not having any type of
renal problems.
GFR is used to assess
kidney function and a
possible chronic kidney
disease. A GFR within the
normal range indicates
that the patient is not
having any kidney
problems.
CK MB is used to
monitor a myocardial
infarction and assess for
any disorders of the
musculoskeletal system.
A CK MB within the
normal range indicates
that the patient does not
have myocardial
infarction or any
musculoskeletal system
disorder.
Troponin I is used to
assess for a cardiac
damage possibly related
to myocardial infarction.
A Troponin I within
normal range shows that
the patient is not having a
myocardial infarction.
Chest x-ray is used to
assist in the evaluation of
cardiac and respiratory
structure within the lung
cavity. The chest x-ray
was performed due to the
right-sided weakness of
the patient and his history
of hypertension. The
chest x-ray showed a

University of South Florida College of Nursing Revision September 2014

Computed Topography (CT), Brain

Acute parenchymal hemorrhage
centered within the left basal
ganglia with intraventricular
extension of blood products.
Chronic small vessel ischemic
disease within the white matter.

(10/12/2015)

Carotid Ultrasound (US)

No sonographic evidence of
hemodynamically significant
common or internal carotid artery
stenosis.

(10/12/2015)

On admission, the CT of
the brain showed an acute
parenchymal hemorrhage
centered within the left
basal ganglia and it also
showed a chronic small
vessel ischemic disease
within the white matter.
This shows that the
patient has a cerebral
infarction and
hemorrhage.

On admission, the carotid

ultrasound showed no
evidence of
hemodynamically
significant common or
internal carotid artery
stenosis. This shows that
the patient does not have
any blockage on his
carotid arteries.

cardiomegaly which
shows that he may have a
cardiovascular disorder
possibly due to his
history of hypertension.
A CT of the brain is used
to visualize and assess the
brain to help diagnose for
tumor, bleeding, infarct,
infection, edema, and any
structural changes. The
CT of the brain was
performed due to the
right-sided weakness,
possible stroke, and
history of hypertension.
The CT showed an acute
parenchymal hemorrhage
centered within the left
basal ganglia and a
chronic small vessel
ischemic disease within
the white matter. This
shows that the patient had
a possible infarction as
well as a hemorrhage that
needs immediate medical
attention.
A carotid ultrasound is
used to visualize and
assess blood flow through
the carotid arteries to help
in evaluating a risk for
stroke related to
atherosclerosis. The
carotid ultrasound was
performed due to the
right-sided weakness,
possible stroke, and
history of hypertension.
The carotid ultrasound
showed no evidence of a
significant common or
internal carotid artery
stenosis. This indicates
that the patient does not
have any blockage on his
carotid arteries that
contributed to his right-

University of South Florida College of Nursing Revision September 2014

Magnetic Resonance Imaging

(MRI), Brain
Acute or recent infarction in the left
external capsule directly adjacent to
the ependymal margin of the left
lateral ventricle. Extensive
parenchymal hemorrhage situated is
slight inferiorly in the left lentiform
nuclei. There is an intraventricular
hemorrhage. Mild extent of
presumptive small vessel ischemic
changes. No focal mass, focal
pathologic enhancement, midline
shift nor abnormal extra-axial fluid
collection.

(10/14/2015)

sided weakness.
The MRI of the brain was An MRI of the brain is
performed two days after used to assess and
admission and it showed
visualize intracranial
an acute or recent
abnormalities related to
infarction adjacent to the tumor, bleeding, lesion,
left lateral ventricle and
and infarct such as stroke.
intraventricular
The MRI of the brain was
hemorrhage. An extensive performed due to his
parenchymal hemorrhage right-sided weakness that
is situated slightly
may be related to a
inferior in the left
possible stroke. The MRI
lentiform nuclei and a
showed an acute or recent
mild extent of
infarction adjacent to the
presumptive small vessel left lateral ventricle and
ischemic changes. This
intraventricular
indicates that the patient
hemorrhage. An extensive
has some bleeding in his
parenchymal hemorrhage
brain and an infarct that
is situated slightly
may have caused the
inferior in the left
right-sided weakness
lentiform nuclei and a
leading to a possible
mild extent of
stroke.
presumptive small vessel
ischemic changes. This
indicates that the patient
has some bleeding in his
brain and an infarct that
may have caused the
right-sided weakness
leading to a possible
stroke. This also shows
that the patient may need
more medical attention
for the possibility of a
stroke.

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

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
The patient has been seen by a neurologist at the emergency department and he will be continuously
monitored by the neurologist in the NICU and neurology medical unit because he developed a hemorrhage in his
left basal ganglia as shown on the brain CT scan that resulted to a hemorrhagic stroke. The patient received
nicardipine (Cardene), a calcium channel blocker, drip to keep his blood pressure lower than 150 mm Hg,
neurologic assessments were performed every two hours in the NICU to monitor for any changes, and a
prescription of hydralazine (Apresoline), a vasodilator, was added for a systolic blood over than 150 mm Hg. In
University of South Florida College of Nursing Revision September 2014

addition, the home medication of the patient which was lisinopril (Prinivil) is continued during this
hospitalization to help control his blood pressure. An MRI of the brain was also done and the results showed an
acute or recent infarction as well as an intraventricular hemorrhage. As the symptoms of the patient became less
critical, he started working with a physical therapist to regain his strength in the neurology medical unit. The
patient was also ordered a mechanical soft diet to prevent aspiration due to his right facial droop and impaired
swallowing He may be discharged to a rehabilitation facility after a few more days of observation.

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

1.Ineffective cerebral tissue perfusion related to interruption of blood flow by cerebral hemorrhage as evidenced by high
blood pressure as well as weakness on right upper and lower extremities.
2. Risk for Aspiration as evidenced by impaired swallowing, depressed cough, and depressed gag reflex.
3. Impaired Physical Mobility related to decreased strength and endurance as evidenced by right-sided weakness as well as
right flaccid upper and lower extremities.
4. Risk for Impaired Skin Integrity as evidenced by immobility and right-sided weakness.
5. Constipation related to neurological impairment by cerebral hemorrhage as evidenced by inability to pass stool and
hypoactive bowel sounds.
6. Ineffective coping related to sudden change in physiological status as evidenced by inability to meet basic needs and
inability to meet role expectation.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Ineffective cerebral tissue perfusion related to interruption of blood flow by cerebral hemorrhage as evidenced by high blood
pressure as well as weakness on right upper and lower extremities (Doenges, Moorhouse, & Murr, 2010).
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on Day Care
Achieve Goal
Provide References
is Provided
Patient will maintain appropriate
1. Assess verbal response every
1. It is important to assess verbal 1. The patient maintained proper
orientation to person, place, time,
four hours or per unit protocol.
response because it measures
verbal responses, alertness, and
and situation by the end of shift.
Note whether client is alert,
appropriateness of speech and
appropriate orientation to
oriented to person, place, and
content of consciousness. It
person, place, and time.
time.
may also tell the amount and
2. The patient maintained
2. Perform a neurological
location of damage in the
baseline neurological status
assessment every four hours or
brain. Damage to midbrain,
with no signs of irregular or
per unit protocol.
pons, and medulla is
change in neurological status.
3. Monitor for changes in mental
manifested by lack or
3. The patient did not show signs
status or behavior every four
appropriate responses to
or changes in mental status or
hours or per unit protocol.
stimuli.
behavior
Note if patient is confused or if 2. It is important to perform a
patient uses inappropriate
neurological assessment
words or phrases that make
because fluctuations in level of
little sense.
consciousness and aphasia are
symptoms of cerebral
vasospasm.
3. It is important to assess
changes in mental status or
behavior because these
changes may lead to decreased
cerebral perfusion (Ackley &
Ladwig, 2011).
Patient will maintain usual or
improve motor and sensory
function by the end of shift.

1. Assess motor response to

simple commands every four
hours or per unit protocol.
Note purposeful movements
such as obeying commands as

1. It is important to assess the

motor response to simple
commands of the patient
because this measures overall
awareness and ability to

University of South Florida College of Nursing Revision September 2014

1. The patient responded to

simple commands such as
squeeze hands, bend knees,
and push feet against
resistance.

well as non-purposeful
movements such as posturing
on right and left side.
2. Note presence or absence of
reflexes blink, cough, gag,
and Babinski reflex every four
hours or per unit protocol.

Patient will maintain stable or

baseline vital signs specifically
blood pressure, heart rate, and
temperature by the end of shift.

1. Monitor blood pressure every

four hours or per unit protocol.
Note onset and continuing
systolic hypertension and
widening pulse pressure.
2. Monitor heart rate and rhythm
every four hours or per unit
protocol. Note bradycardia and
other dysrhythmias.
3. Monitor pattern, rate, and
rhythm of respirations every
four hours or per unit protocol.
Note periods of apnea after
hyperventilation and CheyneStokes respiration.

2.

1.

2.

3.

respond to respond to external

stimuli. Posturing may indicate
diffuse cortical damage.
It is important to note the
presence or absence of reflexes
because altered reflexes reflect
injury at level of midbrain or
brainstem that has direct
implications with the safety of
the patient. On the other hand,
the presence of a Babinski
reflex may indicate injury
along pyramidal pathways in
the brain (Doenges et al.,
2010).
Autoregulation normally
maintains constant cerebral
blood flow despite systemic
blood pressure fluctuations. It
is important to monitor blood
pressure because the widening
pulse pressure is an ominous
sign of increased intracranial
pressure (ICP). Also, the loss
of autoregulation may diffuse
cerebrovascular damage.
Changes in heart rate and
rhythm, most especially
bradycardia, may develop
without impacting
hemodynamic stability.
However, dysrhythmias can
reflect brainstem pressure or
injury in the absence of
underlying cardiac disease.
Irregularities in respirations

University of South Florida College of Nursing Revision September 2014

2. The patient has presence of

reflexes blink, cough, and
gag. The patient was not
assessed for Babinski reflex
because a reflex hammer was
unavailable during the time of
the assessment.

1. The patient maintained his

baseline blood pressure and it
did not show any widening of
pulse pressure.
2. The patient maintained a
regular rate and rhythm. He
did not show any signs of
bradycardia or any other
dysrhythmias.
3. The patient maintained a
regular pattern, rate, and
rhythm of respirations. He did
not show any signs of CheyneStokes respirations or
hyperventilation.

may suggest increasing ICP,

location of cerebral insult, and
the need for further
intervention such as possible
respiratory support (Doenges
et al., 2010).
*Patient will verbalize three
1. Encourage weight loss to the
1. Obesity or being overweight is a 1. The patient is aware that he
lifestyle changes that will help in
patient through teaching moderate risk factor for development of
needs to lose weight and he is
lowering blood pressure by
exercise movements and proper
other health complications like
also aware of his low sodium
discharge.
low sodium diet.
heart disease.
diet. He was able to verbalize
2. Assess the nutritional status of
2. Malnutrition contributes to
ways on how he can control
the client and refer to a dietitian if anemia that compounds to the lack
his diet. The patient was not
appropriate.
of oxygenation to tissues. Obese
able to verbalize exercise
3. Teach the patient two ways to
patients have poor circulation in
movements that he can
reduce stress like meditation and
their adipose tissues which creates
practice.
painting.
increased hypoxia in the tissues
2. The patient verbalized that he
3. Anger and other negative
may refer to a dietitian for an
emotions may play a role in
improvement of his diet.
triggering a stroke
3. The patient verbalized the two
(Ackley & Ladwig, 2011).
ways that he can reduce stress.
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
X SS Consult The patient may need to speak to a social worker with regards to his financial issues because he does not have any health insurance
due to immigration issue.
X Dietary Consult The patient may need to consult with a dietitian with regards to his low sodium diet to prevent him from having high blood
pressure.
X PT/ OT The patient may need physical and occupational therapy for strengthening and self care.
Pastoral Care
X Durable Medical Needs The patient may need a walker and wheelchair for ambulation.
X F/U appointments The patient is required to follow up with his primary care physician one week after discharge.
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH The patient is planned to be discharge to a rehabilitation facility. However, the wife is his primary caregiver.

University of South Florida College of Nursing Revision September 2014

Nursing Diagnosis: Risk for Aspiration as evidenced by impaired swallowing, depressed cough, and depressed gag reflex (Ackley & Ladwig, 2011).

Patient Goals/Outcomes

Nursing Interventions to
Achieve Goal

Rationale for Interventions

Provide References

Evaluation of Goal on Day

Care is Provided

Patient will maintain clear lung

sounds by the end of shift.

1. Monitor respiratory rate,

1. It is important to note signs of
depth, and effort every four
aspiration because it needs to
hours or per unit protocol.
be detected as soon as possible
Note any signs of aspiration
to prevent further aspiration
such as dyspnea, cough,
and to initiate lifesaving
wheezing, and hoarseness.
treatment. It is also important
2. Auscultate lung sounds
to note signs of aspiration
frequently especially before
because laryngeal pooling and
and after feedings every four
residue in clients may result to
hours or per unit protocol.
silent aspiration.
Note any new onset of crackles 2. It is important to auscultate
or wheezing.
lung sounds frequently
because early detection of
crackles or wheezing will
prevent patients from
aspirating by giving early
intervention to these irregular
lung sounds (Ackley &
Ladwig, 2011).

1. The patient maintained a

regular respiratory rate, depth,
and effort. He did not show
any signs of aspiration.
2. The patient maintained clear
lung sounds and he did not
show any abnormal lung
sounds such as crackles or
wheezing.

Patient will swallow and digest

oral feeding without aspiration by
the end of shift.

1. Check the gag reflex of the

1. It is important to check the gag
patient and the ability to
reflex and the ability to
swallow by feeling the
swallow of the patient because
laryngeal prominences as the
if the patient is having trouble
patient attempts to swallow.
swallowing or the patient does
This should be performed prior
not have a good gag reflex
to oral feeding.
then it is important to provide
2. Feed the patient slowly and
intervention. In addition, the
allow adequate time for
patient may not continue oral
chewing and swallowing
feeding if gag reflex is absent
during meal time.
and the patient is unable to
3. Keep head of bed elevated to
swallow.
90 degrees or preferably let the 2. Feeding the patient slowly and

1. The patient maintained his oral

feeding because he was able to
swallow and his gag reflex is
present.
2. The patient was assisted with
his oral feeding and he slowly
ate his food. He also allowed
himself an adequate time for
chewing and swallowing.
3. The patient kept the head of
his bed elevated at 90 degrees
during feeding and he also
kept the head of the bed at 90

University of South Florida College of Nursing Revision September 2014

patient sit up in a chair when

feeding. Keep head elevated
for an hour after feeding.

giving the patient adequate

degrees for an hour after
time to eat will reduce the risk
feeding.
of aspiration. Multiple studies
also show that it takes 35
minutes or more to feed a
client who is interested in
eating.
3. Maintaining a sitting position
with feeding and after meals
may help decrease aspiration
pneumonia for the patient
(Ackley & Ladwig, 2011).
*Patient will verbalize two signs
1. Teach the patient signs of
1. It is important to teach the
1. The patient was able to
and precautions to prevent
aspiration like shortness of breath, patient the signs of aspiration so
verbalize two signs of aspiration
aspiration.
cough, wheezing, and hoarseness. he or his caregiver can monitor for such as cough and shortness of
2. Teach the patient aspiration
these signs during feeding.
breath.
precautions like sitting up when
2. It is important to teach the
2. The patient was able to
eating or avoiding distractions.
patient aspiration precautions so
verbalize two aspiration
he or his caregiver can avoid
precautions such as sitting up
aspiration during feeding (Ackley when eating and avoiding
& Ladwig, 2011).
distractions like the television.
2 Discharge Planning: (put a * in front of any patient education in above care plan that you would include for discharge teaching)
Consider the following needs:
X SS Consult The patient may need to speak to a social worker with regards to his financial issues because he does not have any health insurance
due to immigration issue.
X Dietary Consult The patient may need to consult with a dietitian with regards to his low sodium diet to prevent him from having high blood
pressure.
X PT/ OT The patient may need physical and occupational therapy for strengthening and self care.
Pastoral Care
X Durable Medical Needs The patient may need a walker and wheelchair for ambulation.
X F/U appointments The patient is required to follow up with his primary care physician one week after discharge.
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH The patient is planned to be discharge to a rehabilitation facility. However, the wife is his primary caregiver.
Palliative Care
University of South Florida College of Nursing Revision September 2014

References
Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care.
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Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing care plans: Guidelines for individualizing
client are across the life. Philadelphia, PA: F.A. Davis Company.
Huether, S., & McCance, K. (2012). Understanding Pathophysiology. St. Louis, MO: Mosby Elsevier.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing: Assessment
and management of clinical problems. St. Louis, MO: Mosby Elsevier.
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for
practice (2nd ed.). Upper Saddle River, NJ: Pearson Education Incorporated.
Treas, L.S., & Wilkinson, J.M. (2014). Basic Nursing: Concepts, skills, and reasoning. Philadelphia, PA: F.A.
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USDA (n.d.) Supertracker. Retrieved from http://supertracker.usda.gov

University of South Florida College of Nursing Revision September 2014