UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: My Nguyen |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 2/2/16 |

| ( 1 PATIENT INFORMATION |Agency: FHT |

|Patient Initials: W.B |Age: 67 |Admission Date: 1/20/16 |

|Gender: Female |Marital Status: Married |Primary Medical Diagnosis: Pleural effusion |

|Primary Language: English | |

|Level of Education: 2 yrs of college |Other Medical Diagnoses: (new on this admission) |

| |Chronic Kidney Disease (CKD) Stage 3 |

|Occupation (if retired, what from?): retired from HCC | |

|Number/ages children/siblings: 3 biological daughters – 47, 44, 43yo/ 1 stepson/ 4 siblings | |

|Served/Veteran: No |Code Status: Full resuscitation |

|If yes: Ever deployed? | |

|Living Arrangements: Currently living with husband and 2 dogs in a one-story house. Pt is |Advanced Directives: Yes |

|able to drive herself. She also has her youngest daughter who is able to help when needed. |If no, do they want to fill them out? |

| |Surgery Date: 1/21 Procedure: Pigtail chest tube |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: Baptist |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: |

|Pt “couldn’t breath.” |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) |

|Pt was admitted on 1/20 due to difficulty breathing as pt reported she “couldn’t breath.” Pt also had “chest pain” that was “sharp” and was rated as an “8 to a 9.”|

|This is actually the second time she is hospitalized for the same problem. Pt was admitted to Florida Hospital Wesley Chapel in the beginning of December 2015. She|

|reported having a chest tube inserted to drain the fluid and then was discharged. Pt denied nausea or vomiting. No relieving factor noted. A chest tube was |

|inserted, and pt’s condition improved. |

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

|Date |Operation or Illness |

|N/A |Cholecysteromy |

|N/A |Hysterectomy |

|N/A |HTN – Olmesartan |

|N/A |Hyperlipidemia – no med prescribed, pt managed through diet |

|N/A |Diabetes – diet mgt |

|1/21/16 |CKD Stage 3 |

|1/20/16 |Pleural effusion |

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|( 2 FAMILY MEDICAL HISTORY |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) Is within 10 years? 2012 | | |

|Influenza (flu) (Date) Is within 1 years? December 2015 | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? 2015 | | |

|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 |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Atarax |Nausea |

| |Codeine |Nausea |

| |Colace |Severe diarrhea |

| |Erythromy |Nausea |

| |Floxin |Sleepy/sedated |

| |Keflex |Anaphylactic |

| |Penicillin |Hives |

| |Statins |Severe migraine |

|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) |

|Pleural effusion is the accumulation of fluid in between the parietal and visceral pleura. Normally, there is a small amount of fluid between the two surfaces to |

|act as lubricant for the chest wall and lung to glide across each other. In a normal process, the “fluid enters the pleural space via capillaries and exits via |

|stomas and lymphatic” (Osborn, Wraa, Watson & Holleran, 2014, 780). However, as the fluid increases in the thoracic cavity, it can compress the lung, causing the |

|diaphragm to be depressed. Additionally, with large effusions, the pressure may be too much on the heart, leading to cardiac tamponade. Pleural effusion can also |

|be categorized into exudative (inflammation or injury causing protein and cellular debris to be deposited into the tissue) or transudative (“caused by a change in |

|oncotic pressure that is not inflammatory”) (Osborn et. al, 2014, 779). Other types of pleural effusions are based on the microogranisms, such as empyema, |

|hemothorax, or chylothorax. Some patient may be asymptomatic, but some of the clinical manifestations include: chest pain that are sharp, unilateral, and worse |

|with inspiration or cough, the pain could radiate to the shoulder or neck, and lung sound will be diminished. Dullness to percussion, absent tactile fremitus, and |

|pleural friction rub are also noted. It is diagnosed through a chest X-ray and thoracentesis (needle aspiration), to determine the type of effusion, but can also |

|be used to “remove enough fluid to relieve dyspnea” (Osborn et. al., 2014, 780). Treatment range from chest tube to surgical intervention such as pleurodesis, “a |

|procedure that eliminate the pleural space by injecting a chemical irritant into the space that induces inflammation and fibrosis” (Osbron, et. al., 2014, 780). |

|More than 50 disorders can cause this illness, but the risk increases for those with CHF, PE, infection, drug usage, renal disorder, and cirrhosis. Prognosis is |

|high with early detection, and low with malignancy pleural effusion. |

| |

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

|Name cholecalciferol (Vitamin D) |Concentration |Dosage Amount 2500mcg |

|Route PO |Frequency daily |

|Pharmaceutical class Fat soluble vitamins |Both |

|Indication Treatment of vitamin D deficiency |

|Adverse/ Side effects headache, photophobia, hypertension, constipation, dry mouth, pancreatitis, pruritus, muscle pain, hypercalcemia |

|*With toxicity |

|Nursing considerations/ Patient Teaching |

|Take med as directed; ingestion of food high in calcium may lead to hypercalcemia; notify provider if toxic symptoms appear (vomiting, anorexia, constipation, |

|headache, muscle pain, photophobia) |

|Name cyanocobalamin (Vitamin B12) |Concentration |Dosage Amount 100mcg |

|Route PO |Frequency daily |

|Pharmaceutical class Water soluble vitamin |Both |

|Indication Vitamin B12 deficiency |

|Adverse/ Side effects Headache, heart failure, diarrhea, itching, swelling of the body, pulmonary edema, anaphylaxis |

|Nursing considerations/ Patient Teaching |

|Take med as directed; comply with diet (food high in B12 includes meat, seafood, egg yolk, cheese) |

|Name docusate (Colace) |Concentration |Dosage Amount 100mg |

|Route PO |Frequency Q12H |

|Pharmaceutical class stool softeners |Hospital - not given for past 1 day due to reaction |

|Indication Prevention of constipation |

|Adverse/ Side effects throat irritation, mild cramps, diarrhea, rashes |

|Nursing considerations/ Patient Teaching |

|Use for short-term therapy; use other forms of bowel regulation (increase fluid, fibers, mobility); do not take laxative when abd. pain or fever is present |

|Name famotidine |Concentration |Dosage Amount 20mg |

|Route PO |Frequency daily |

|Pharmaceutical class histamine h2 antagonist (antiulcer agents) |Hospital |

|Indication Prevention of stress ulceration |

|Adverse/ Side effects confusion, dizziness, constipation, diarrhea, anemia, agranulocytosis, arrhythmias |

|Nursing considerations/ Patient Teaching |

|Take med as directed; smoking interferes with histamine antagonist; avoid alcohol and products containing aspirin or NSAIDs; notify provider if black, tarry |

|stools, fever, sore throat, dizziness, rash |

|Name hydralazine (Apresoline) |Concentration |Dosage Amount 25mg |

|Route PO |Frequency Q6H |

|Pharmaceutical class Vasodilator (antihypertensives) | Hospital |

|Indication moderate to severe hypertension |

|Adverse/ Side effects dizziness, drowsiness, tachycardia, angina, orthostatic hypertension, diarrhea, N/V, rash, sodium retention, drug-induced lupus syndrome |

|Nursing considerations/ Patient Teaching |

|Take med as directed; alcohol and other antihypertensives may increases risk of hypotension; comply with other intervention to lower hypertension (diet, exercise);|

|change position slowly; notify provider if chest pain, rash, sore thorat, numbness or tingling of hands and feet occurs. |

|Name Insulin Lispro (Humalog) - short acting |Concentration |Dosage Amount medium dose |

|Route INJ Subcutaneous |Frequency WMHS |

|Pharmaceutical class pancreatics (antidiabetics) | Hospital |

|Indication Control of type 2 diabetes |

|Adverse/ Side effects hypoglycemia, lipodystrophy, pruritis, erythema, swelling, anaphylaxis |

|Nursing considerations/ Patient Teaching |

|Take med as directed; it controls but does not cure the illness; comply with diet and exercise regime; instruct pt on hypo- and hyperglycemia S/S and to notify |

|provider; keep candy on hands |

|Name Nifedipine (Procardia) |Concentration |Dosage Amount 30mg |

|Route PO |Frequency Daily |

|Pharmaceutical class calcium channel blockers | Hospital |

|(antianginals/antihypertensives) | |

|Indication hypertension |

|Adverse/ Side effects headache, anxiety, confusion, dizziness, blurred vision, tinnitus, cough, dyspnea, arrhythmias, HF, peripheral edema, bradycardia, |

|hypotension, constipation, nocturia, flushing, rash, hyperglycemia, weight gain, anemia, gingival hyperplasia |

|Nursing considerations/ Patient Teaching |

|Take med as directed; good oral hygiene; avoid grapefruit as it increases effect; do not take if HR is ................
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