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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Anthony Ortiz


Assignment Date: 10/20/16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRMC
 1 PATIENT INFORMATION
Patient Initials: RT Age: 63 Admission Date: 10/19/16
Gender: Male Marital Status: Married Primary Medical Diagnosis: HIV, lung cancer
(metastasized to liver and bone)
Primary Language: English
Level of Education: Bachelor’s degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): retired (Perkins general manager) Abdominal pain
Number/ages children/siblings: 3 sisters (60, 57, 46)

Served/Veteran: Code Status: Full


If yes: Ever deployed? Yes or No
Living Arrangements: With husband, daughter, and granddaughter Advanced Directives: No
in one story house. If no, do they want to fill them out? No
Surgery Date: N/A Procedure:
Culture/ Ethnicity /Nationality: Caucasian
Religion: Baptist Type of Insurance: Cigna

 1 CHIEF COMPLAINT:
Patient complains of abdominal pain. Patient states, “it’s getting in the way of the little time I have left.”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 63-year-old, married male who presented to the emergency department with abdominal pain. His husband,
who also served as his transport to LRMC, accompanied him. The patient has had flare ups of this pain that started 4
months prior to this admission. The pain is centered on the abdomen and manifests itself in short spurts. The patient
describes the pain as alternating between a stabbing and aching feeling. Aggravating factors include ingesting cold
sustenance such as iced tea and milk. The patient is able to find some relief from ingesting warm sustenance, such as
warm tea or chicken broth. Aside from pain medication, the patient uses ginger ale to treat his symptoms. He rates his
pain at a 5 out of 10. Health care team concluded that pain was due to metastasized cancer in the liver.

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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
6/2/16 Neck dissect
8/11/16 Port A catheter insert
8/30/16 Heart stent

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL Glaucoma

Problems

Problems
Allergies

of
Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death Gout
(if
applicable)
Father 83
Mother 79 Cancer
Sister 60
Sister 57
Sister 46
relationship

relationship

Comments: Include age of onset

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
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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
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
NKA

Medications

NKA
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)
Lung cancer is described as an uncontrollable growth of cells within the lungs. It is considered to be the leading cause of
cancer-related death in both men and women worldwide. Lung cancer primarily occurs in patients between the ages of 45
and 75. The greatest risk of lung cancer lies in people use tobacco products such as cigarettes and cigars. Lung cancer can
also develop in nonsmokers via secondhand smoke. Tumors can form in any place within the lung, but symptoms don’t
usually appear until they have reached an advanced stage or traveled to another part of the body. Symptoms of the disease
include incessant coughing or wheezing, shortness of breath, chest pain, unexplained weight loss, and an increased
susceptibility to lower respiratory infections. A diagnosis of lung cancer is often discovered while examining for other
conditions. Procedures for detecting cancerous lung cells include x-rays, CAT scans, PET scans, and MRI’s. Blood tests
can also be performed to search for proteins and other substances known to be associated with lung cancer. Unfortunately,
diagnosis of most cases of lung cancer comes after the disease has already spread, or metastasized from its original
location. Lung cancer metastasizes to areas such as the bone, liver, kidney, and brain. For these reasons, poorer prognoses
accompany lung cancer. Similar to other cancers, primary treatments include surgery, chemotherapy, and radiation.
General health, stage of the disease, and the type of cancer are determining factors in the choice of treatment (Huether, S.
E. & McCance, 2012).

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: diltiazem (Cardizem) Concentration: 180mg/tab Dosage Amount: 180mg

Route: oral Frequency: Daily


Pharmaceutical class: Calcium channel blocker Home: Hospital or Both
Indication: HTN, angina, arrhythmias
Adverse/ Side effects: dizziness, drowsiness, anxiety, weakness, arrhythmias, CHF, peripheral edema
Nursing considerations/ Patient Teaching: Report unrelieved chest pain, SOB immediately.

Name: famciclovir (Famvir) Concentration: 500mg/tab Dosage Amount: 500mg

Route: oral Frequency: daily


Pharmaceutical class: Antiviral Home: Hospital or Both
Indication: genital herpes, shingles, chickenpox
Adverse/ Side effects: dizziness, headache, diarrhea, nausea, seizures, renal failure

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Nursing considerations/ Patient Teaching: Wear condoms during sexual contact. Wash hands after touching affected areas to avoid spreading.

Name: lamivudine (Epivir) Concentration: 150mg/tab Dosage Amount: 150mg

Route: oral Frequency: BID


Pharmaceutical class: Antiretroviral Home: Hospital or Both
Indication: HIV/AIDS
Adverse/ Side effects: headache, insomnia, vomiting, nausea, hepatotoxicity, hypersensitivity
Nursing considerations/ Patient Teaching: Do not share needles or donate blood. Report signs of allergic reactions.

Name: nevirapine (Viramune) Concentration: 200mg/tab Dosage Amount: 200mg

Route: oral Frequency: BID


Pharmaceutical class: Antiretroviral Home: Hospital or Both
Indication: HIV
Adverse/ Side effects: nausea, abdominal, drowsiness, impaired concentration
Nursing considerations/ Patient Teaching: Do not share needles or donate blood. Report signs of rash to HCP.

Name: pantoprazole (Protonix) Concentration: 40mg/tab Dosage Amount: 40mg

Route: oral Frequency: daily


Pharmaceutical class: Proton-pump inhibitor Home: Hospital or Both
Indication: GERD, duodenal ulcers, upper GI bleed
Adverse/ Side effects: headache, flatulence, diarrhea, abdominal pain, rash
Nursing considerations/ Patient Teaching: Avoid alcohol, aspirin, NSAIDS, smoking, caffeine, and food that cause gastric distress.

Name: nicotine Concentration: 14mg/patch Dosage Amount: 14mg

Route: topical Frequency: daily


Pharmaceutical class: smoking cessation aid Home: Hospital or Both
Indication: Adjunct in smoking cessation therapy
Adverse/ Side effects: Nausea, vomiting, diarrhea, hiccups, heartburn, dizziness, palpitations, hypertension, mouth problems
Nursing considerations/ Patient Teaching: Do not smoke cigarettes or use other nicotine products while using nicotine skin patches because of overdose risk.

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Route Frequency

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Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Clear liquids Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? regular Consider co-morbidities and cultural considerations):
24 HR average home diet: The patient does well with his intake of vegetables, but he
lacks proper nutrition in other areas. The patient should
reduce his intake of refined grains and increase his intake of
whole grains, which can be done by substituting whole
grain bread, pasta, and other food products into his diet.
The patient can increase his intake of fruits and dairy in a
simpler way, such as combining fruits and yogurt into a
smoothie or substituting more fruit into his meals in place
of less healthy options. At 162% of the daily-recommended
intake, the patient is way over the target amount for protein.
Excessive amounts of protein in the body can be converted
to sugar and then fat. The patient should substitute some of
his protein intake with more whole grain. Though the intake
of saturated fat is at a healthy range, the amounts of added
sugars and sodium are also over their recommended
amounts. The patient can lower these amounts by avoiding
foods with too much added sugar and high levels of
sodium.
Breakfast: oatmeal, toast, coffee

Lunch: turkey sandwich

Dinner: potatoes, broccoli, grilled chicken

Snacks: chocolate cake, grapes

Liquids (include alcohol): coffee, hot tea, pepsi

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.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Michael (patient’s husband).
How do you generally cope with stress? or What do you do when you are upset?
“I go in my room and shut the door. If no one bothers me for a while I’ll cool down.”

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Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“Sometimes my anxiety acts up. When it does, I take a Xanax.”

+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? ______________________

Are you currently in a safe relationship? yes

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
“Stagnation occurs when development ceases: A stagnant middle adult cannot guide the next generation or contribute to
society” (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
In the patient’s current state, he feels that he has not accomplished all that he originally set out to do. He feels that he has
been unsuccessful in providing for his family and preparing a better future for them. The disease has caused him to
experience a sort of midlife crisis, where he feels that there is so much he hasn’t gotten to do, and still wants to do. The
patient feels as though he’s provided a poor transition for both himself and his family in the wake of his prognosis of 12-
14 months of life remaining. His mind is riddled with thoughts of regret concerning many of his life choices; primarily
that of his decision to continue to smoke. The patient’s biggest concern is leaving behind his husband to death with the
aftermath of his poor decisions. His husband has been through every last bit of the last 41 years with him, and the patient
feels as though he’s failed him.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The patient’s current hospitalization further intensifies his feelings of guilt and regret. He has tried to comes to terms with
the reality of his condition, but that has proven to be extremely difficult.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
”Smoking cigarettes.”

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What does your illness mean to you?
“Stupid, you should’ve quit smoking.”

+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
(herpes/HIV)____________________________________________
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? _____condoms_____________________________

How long have you been with your current partner?____41


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

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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
“It’s helped me through tough times, especially with the
cancer.”_____________________________________________________________________________________________________
_
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____no__________________________________________________________________________________________________
______________________________________________________________________________________________________

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


1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 47 years
Cigarettes 1 pack/day (age 16 thru present)

If applicable, when did the


Pack Years: 47
patient quit?

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? If yes, what did they use to try to quit? Nicotine patches
N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 1or 2 glasses For how many years? 47
Vodka/cranberry
Volume: 8-16 oz (age 16 thru present)
Margaritas
Frequency: 1x/month
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Matijuana How much? 1 joint/day For how many years? 47
(age 16 thru present)

Is the patient currently using these drugs?


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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
no

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

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 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 30 Diverticulitis Life threatening allergic reaction
Bathing routine: 1x/day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? November 2015
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: O
Normal frequency of urination:
Post-nasal drip Other:
4x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth
Diabetes Type:
1x/day
Routine dentist visits
Hypothyroid /Hyperthyroid
1x/year
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 10/19/16 menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Date of last prostate exam? March
Chest pain / Angina Anxiety
2015
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
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Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 10/19/16 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 40lbs
Time frame? December 2015-present
Intentional? No
How do you view your overall health? “Pretty terrible.”

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

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±10 PHYSICAL EXAMINATION:

General Survey: Patient Height: 5’5” Weight: 47.1 kg BMI: 17.1 Pain: (include rating and
is a 63-year-old male Pulse: 92 Blood Pressure: (include location) location)
who shows no signs of Respirations: 24 182/92 Abdomen, 5
distress.
Temperature: (route SpO2: 94 Is the patient on Room Air or O2
taken?) 36.7 (oral)
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]


awake, calm, relaxed, interacts well with others, judgment intact

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


clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact
*patient has mediport on upper right chest, no swelling/redness/pain
Skin turgor elastic
*skin with diminished turgor
No rashes, lesions, or deformities
*bruise on right elbow
Nails without clubbing Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
*patient has very little hair, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: mediport Location: upper right chest Date inserted:
10/19/16
Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 4mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: teeth yellowing, bottom front teeth missing
Comments:

Pulmonary/Thorax: Respirations regular and unlabored


*respirations elevated at 24 bpm
Transverse to AP ratio 2:1 Chest expansion symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
University of South Florida College of Nursing – Revision September 2014 12
Lung sounds:
RUL cl LUL cl
RML cl LLL cl
RLL cl

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


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

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: [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 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
*abdomen tender to palpation
Last BM: (date 10 / 20 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid
Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other – Describe:

GU Urine output: Clear Cloudy Color: dark yellow Previous 24 hour output: N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: Full ROM intact in all extremities without crepitus


Strength bilaterally equal at ___5____ RUE ___5____ LUE ___5____ RLE & ___4____ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative
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

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±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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis


WBC – 3.4 10/20/16 Decrease (from 3.7) Low due to WBC
damage caused by
chemotherapy. The
normal range is 4.5-11.
RBC – 2.23 10/20/16 Decrease (from 2.76) Low due to anemia
caused by chemotherapy.
Normal range 4.7 to 6.1
Hgb – 7.9 10/20/16 Decrease (from 9.3) Low due to anemia
caused by chemotherapy.
The normal range of
12.0-15.5.
Hct – 23.4% 10/20/16 Decrease (from 27.6) Low due to anemia
caused by chemotherapy.
The normal range 36-48.
Plt – 55 10/20/16 Decrease (from 65) Low due to
thrombocytopenia caused
by chemotherapy.
Normal range 150,000 to
450,000.
Glucose - 112 10/20/16 Decrease (from 129) High due to stress caused
by chemotherapy.
Normal range is 70-99
fasting.
BUN - 8 10/20/16 Decrease (from 9) Patient’s BUN within
normal range. The
normal range of 7-20.
Na - 141 10/20/16 Decrease (from 143) Patient’s sodium within
normal range. The
normal range of 135-145
K – 3.6 10/20/16 Increase (from 2.9) Patient’s potassium
within normal range. The
normal range 3.5-5.0.
Cl - 105 10/20/16 Decerase (106) Patient’s chloride within
normal range. The
normal range of 96-106.
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+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.)
Diet: clear liquid, prevents overstimulation of the GI tract
Vitals: every 4 hours, it is standard protocol to take vitals every 4 hours
Activity: ambulation at least once per hour, promotes circulation and improves pain and mobility
Scheduled diagnostic tests: none
Consults: none

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


1. Risk for infection related to mediport.

2.Risk for falls related to dizziness as a side effect of chemotherapy.

3. Ineffective self-health management related to cigarette smoking as evidenced by patient statement of, “If I’m only going
to live 12-14 months, there’s no point in quitting.”

4. Hopelessness related to current prognosis as evidenced by patient’s statement of, “I’ll never be able to provide for my
family the way I really wanted to.”

5. Risk for situational self-esteem related to disease process and unavoidable lifestyle changes.

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± 15 CARE PLAN
Nursing Diagnosis: Risk for infection related to mediport.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will remain free of infection Observe and report signs of “Change in mental statues, fever, Patient shows/reports no signs of
during length of stay. infection such as redness, warmth, shaking, chills, and hypotension infection (i.e. redness, discharge,
discharge, and increased body are indicators of sepsis (Ackley, increased body temperature, etc.).
temperature. 2014, p. 481).”
Assess skin for color, moisture, “Hospital-acquired pressure areas,
texture, and turgor. Keep accurate, skin tears, and infections are
ongoing documentation of changes. associated with pain, reduced
mobility, increased risk of in-
hospital complications, and
increased health care costs
(Ackley, 2014, p. 481).”

Patient will demonstrate Recommend responsible use of “Use and misuse of antibiotics Patient demonstrates proper
appropriate care of infection-prone antibiotics; use antibiotics results in several problems, the techniques when caring for the
site for future care/maintenance. sparingly. most significant of which are infection-prone site.
increases in resistance (Ackley,
2014, p. 482).”
Assess and treat wounds in the “Home-based wound care, when
home. combined with comprehensive
nursing assessment, can be
effective while reducing costs.
Success can be achieved through
the implementation of multiple
clinical, educational, and
operational strategies
simultaneously (Ackley, 2014, p.
483).”

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


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

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


± 15 CARE PLAN
Nursing Diagnosis: Risk for falls related to dizziness as a side effect of chemotherapy.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will remain free of falls Screen all clients for balance and “It is helpful to determine the Patient did not suffer any falls
during length of stay. mobility skills. client’s functional abilities and during length of stay.
then plan for ways to improve
problem areas or determine
methods to ensure safety (Ackley,
2014, p. 333).”
Recognize that when people attend “Those who slow down when
to another task while walking, such given a carrying task are at a higher
as carrying a cup of water, risk for subsequent falls (Ackley,
clothing, or supplies, they are more 2014, p. 333).”
likely to fall.

Patient will verbalize Teach the client how to safely “Safe use of walking aids and Patient was able to repeat,
understanding of methods to ambulate at home, including using assistive devices is crucial to safety verbalize, and stress the importance
prevent injury. safety measures such as hand rails and prevention of future falls of methods to prevent injury at
in bathroom, and need to avoid (Ackley, 2014, p. 337).” home and when in the outside
carrying things or performing other world.
tasks while walking.
Teach the client the importance of “Exercise can prevent falls in older
maintaining a regular exercise people. Greater relative effects are
program. If the client is afraid of seen in programs that include
falling while walking outside, exercises that challenge balance
suggest he or she walk the length and use a higher dose of exercise
of a local mall. than just walking programs
(Ackley, 2014, p.337).”

University of South Florida College of Nursing – Revision September 2014 18


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

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


References

Ackley, B. J. (2014). Nursing diagnosis handbook (10th ed.), St. Louis, MO: Elsevier Mosby

Food Tracker. (n.d.). Retrieved October 24, 2016, from https://www.supertracker.usda.gov/foodtracker.aspx

Huether, S. E. & McCance, K. L. (2012). Understanding pathophysiology (5th ed.), St. Louis, MO:

Elsevier Mosby.

Kee, J. L., Hayes, E. R., McCuistion, L. E. (2015). Pharmacology: a patient-centered nursing process

approach (8th ed.). St. Louis, MO: Elsevier Saunders.

Treas, L. S., Wilkinson, J. M. (2014). Basic nursing concepts, skills & reasoning. Philadelphia, PA: F.A Davis

Company.

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