UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Vanessa Rushing
Assignment Date: 10-20-16
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
 1 PATIENT INFORMATION
Patient Initials: DK Age: 58 Admission Date: 10-16-16
Gender: Male Marital Status: Married Primary Medical Diagnosis: Adenocarcinoma Of
Pancreas
Primary Language: English
Level of Education: High School (12th Grade) Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Construction -Pancreatic Mass
-Malignant Neoplasm of the Pancreas
Number/ages children/siblings: Children (5): Ages- 20,22,29, 32,
36
Siblings (3): Ages- 60, 56, 50
Served/Veteran: Yes Code Status: Full
If yes: Ever deployed? Yes
Living Arrangements: Lives in a house with ex-wife as primary Advanced Directives: No
care giver. There are no obstacles in the house like stairs or If no, do they want to fill them out? No
dangerous objects in the house.
Surgery Date: 10-20-16 Procedure:
Pancreatectomy & Spleenectomy
Culture/ Ethnicity /Nationality: Caucasian
Religion: Christian Type of Insurance: Blue Cross Blue Shield

 1 CHIEF COMPLAINT: The patient states “ I came to the hospital because I thought I had a kidney
Infection but I was wrong. They told me that there is a mass on my pancreas and that its cancer,”.

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 58 year old married Caucasian male who was admitted to the hospital on 10-16-16 to the ED believing
That he had a kidney infection. After multiple tests and labs it was discovered that the patient has pancreatic cancer
On the body of the pancreas. The patient was experiencing symptoms for about 2 months, noting that the back pain in the
Lower quadrants was what was the worst. The patient came in now because the s/s were becoming more and more severe.
The patient is scheduled to have a splenectomy and a pancreatectomy on 10-20-16. The patient was admitted to the
Oncology floor because they are equipped with the best personnel who know how to treat cancer patients, have the proper
Equipment and are in communication with the oncologists and surgeons. The patient will receive more tests post-
operation to see if the cancer in the pancreas is completely gone or not. The patient will receive his post-operative care
And treatment on the oncology floor or on the SICU but no decision has been made yet. Depending on how the surgery
Goes further treatment options will be expressed to the patient and his family to discuss the best ones for him.

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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
10-20-16 Pancreatectomy
10-20-16 Splenectomy
Unknown Hernia Surgery

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)
Colon
Father 85
Cancer
Mother 83
Brother 56
Sister 60
Relationship
Sister 50
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? Yes
Influenza (flu) (Date) Is within 1 years? Yes
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes

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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
No Medication
Allergies

Medications

No Other allergies
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)
Adenocarcinoma of the pancreas occurs when the cells of the pancreas develop mutations in the DNA which cause the
Cells to start to replicate uncontrollably which then eventually turn into a tumor. This type of cancer is where the cancer
Cells begin in the line of the ducts of the pancreas and continue to grow. Risk factors include race (African Americans are
More prone), excess body weight, chronic inflammation of the pancreas, diabetes, personal or family history of pancreatic
Cancer, smoking, and genetics. Ways to be diagnosed include imaging tests that visualize the organs, an endoscopic
Ultrasound that gives images of the pancreas from inside the abdomen, and a biopsy of the pancreatic tissue. Treatment
Varies for each patient based on the stage of the cancer and the state of the patient. Options include surgery to remove the
Parts of the pancreas that have lesions or tumors, radiation therapy, chemotherapy, and clinical trials. The prognosis for
Pancreatic cancer is not good with very low survival rates. Only 7 % of pancreatic cancer patients make it to the 5 year
Mark. This is all due to the fact that by the time the cancer is found the cancer has metastasized to another part of the
Body already, lowering chances of survival.

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Docusate Senna Concentration: 1 tablet Dosage Amount 1 Tablet

Route: Oral Frequency: bid

Pharmaceutical class: Stool softener/ Laxative Home Hospital or Both
Indication: Makes bowel movements softer/easier to pass; Stimulates muscle movement
Adverse/ Side effects: GI cramping, rash, gas, bloating, Nausea, Diarrhea
Nursing considerations/ Patient Teaching: Take with a full glass of water, take at nighttime/bedtime, discontinue after 7 days

Name: Metronidazole (Flagyl) Concentration: 250 mg= 1 tablet Dosage Amount: 250 mg

Route: Oral Frequency: bid

Pharmaceutical class: Antibiotic Home Hospital or Both
Indication: Bowel prep, fights off bad bacteria in the body
Adverse/ Side effects: Dizziness, diarrhea, stomach pain, dry mouth, cough, sneezing, white patches

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Nursing considerations/ Patient Teaching: Take for full length of time, swallow whole, NO alcohol

Name: Famotidine Concentration: 20 mg = 1 tablet Dosage Amount: 20 mg

Route: oral Frequency: Pre-Op

Pharmaceutical class: Histamine -2 Blocker Home Hospital or Both
Indication: Decreases amount of acid in the stomach
Adverse/ Side effects: N/V, diarrhea, constipation, arrhythmias, alopecia, flushing
Nursing considerations/ Patient Teaching: No alcohol, may impair thinking

Name: Metoprolol (Lopressor) Concentration: 25mg= 1 tablet Dosage Amount: 25 mg

Route: oral Frequency: Pre-Operative

Pharmaceutical class: Beta Blocker Home Hospital or Both
Indication: Prevent MI, increase circulation
Adverse/ Side effects: HYPOtension, bradycardia, diarrhea, nausea, tiredness
Nursing considerations/ Patient Teaching: Hold if HR <50 or systolic BP is <100, take with a meal

Name: acetaminophen-oxycodone Concentration: 1 tablet = 325 mg/5 mg Dosage Amount: 325 mg/ 5 mg

Route: Oral Frequency: PRN, q4h

Pharmaceutical class: Analgesic/Opiod Home Hospital or Both
Indication: Treat moderate pain- rate of 4-6 on a 0-10 scale
Adverse/ Side effects: Rashes, sweating, blurred vision, drowsiness, dizziness, hallucinations
Nursing considerations/ Patient Teaching: Oxycodone can be habit forming, no alcohol, do not stop suddenly after long term use

Name: Nitroglycerin Concentration: 0.4 mg = 1 tablet Dosage Amount: 0.4 mg

Route: Sublingual Frequency: PRN, q5min

Pharmaceutical class: Vasodilator Home Hospital or Both
Indication: Treats angina, opens blood vessels to improve blood flow
Adverse/ Side effects: Headaches, dizziness, N/V, flushing, pale skin, weakness
Nursing considerations/ Patient Teaching: Headaches are common but will go away, notify the doctor if pain in unrelieved after 3 doses, hold medicine if HR <
50 and/or if systolic BP is < 90

Name: Ondansetron Concentration: 4 mg = 2 mL Dosage Amount: 4mg

Route: INJ, IV Push Frequency: PRN, q4hr

Pharmaceutical class: Anti-emetic Home Hospital or Both
Indication: Treats nausea and vomiting
Adverse/ Side effects: Headache, sedation, fatigue, hypotension, bradycardia
Nursing considerations/ Patient Teaching: Impair thinking and reactions, be careful if driving

Name: Al Hydroxide Concentration: 15 mL Dosage Amount: 15 mL

Route: Oral Frequency: PRN, q4hr

Pharmaceutical class: Antacid Home Hospital or Both
Indication: Treats dyspepsia
Adverse/ Side effects: Constipation, diarrhea, hypophosphatemia, malaise, muscle tiredness
Nursing considerations/ Patient Teaching: Watch for electrolyte imbalances

Name: D5/0.45S + KCC (IV Fluids) Concentration: 20 mEq = 1,000 mL Dosage Amount: 20 mEq

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Route: IV Frequency: 75 mL/ hr, 13.3 hours
Pharmaceutical class: Electrolyte Solution Home Hospital or Both
Indication: replenish fluids in the body, keep patient from becoming dehydrated during stay in hospital
Adverse/ Side effects: Rash around site, irritation at site, hypervolemia
Nursing considerations/ Patient Teaching: Watch IV site for redness, tenderness, watch for infiltration, hematomas

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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? Regular, NPO at time of Analysis of home diet (Compare to “My Plate” and
interview
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Patient states that they do not normally eat According to MyPlate not having a breakfast can be
breakfast detrimental to ones health since it is the most important
meal of the day! MyPlate suggests that even if someone
does not want to eat a large breakfast a fruit cup or even
some yogurt would be beneficial. MyPlate suggests that
this patient consume more fruit and vegetables to begin
with since the patient does not consume any in their regular
daily diet. Suggested for him is 1 cup of fruit a day and for
vegetables it is recommended that he consume 2.5 cups a
day. These can be eaten as snacks or as sides at dinner or
breakfast.

Lunch: Sushi (Tempura fish), Mac & Cheese, French fries, MyPlate suggests that the patient cut back on the amount of
water carbohydrates that the patient consumes in one meal and on
a daily basis since that seems to be his main source of food
per meal. It is suggested that the patient only consume
around 6 ounces of grains per day.

Dinner: Some kind of meat or meatloaf, Baked Potato, The patient can consume more protein in his diet which
Grape Juice would help keep him feeling better. It is suggested that he
consume around 5.5 ounces of protein a day to keep his diet
healthy.

Snacks: ice cream, Brownies Although brownies and ice cream are delicious it is
recommended that these food items stay as a dessert or treat
for every now and then and not as snacks. Instead options
can include cheese and crackers, fruit, or granola bars
instead.

Liquids (include alcohol): Water, juice, alcohol: 1 beer or The patient does not overconsume alcohol and has a good
wine a week set of drink choices.

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? The patient states “My wife helps me a lot. She makes my doctors appointments for me
and actually makes sure that I go,”.

How do you generally cope with stress? or What do you do when you are upset?
The patient states “Usually I’ll go out to the barn that we have and do some work on it. It is a nice stress reliever,”.
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The patient states “When I’m upset I do the same thing, go to the barn,”.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient has begun to recently have anxiety and feeling overwhelmed due to the patient’s recent diagnosis of cancer.

+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? No

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: According to McLeod (2013) “During middle adulthood (ages 40 to 65 yrs), we establish our careers, settle down
within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society
through raising our children, being productive at work, and becoming involved in community activities and organizations. By failing
to achieve these objectives, we become stagnant and feel unproductive. Success in this stage will lead to the virtue of care.”

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is currently in the generativity stage of his life. Even though my patient was newly diagnosed with cancer he is
Still full of life, humor, and has a strong support system at his side. My patient is a father of 5 children, the youngest one
Aged 20 so he is still raising children and giving back to society through that and his current occupation of construction.
My patient is in no way stagnant in his life and continues to want to get healthy so he can get back to doing what he wants
To be able to do and get out of bed. He is known to be very busy and always doing something so that to me proves that he
is in the generativity stage of his life instead of the stagnation stage.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
My patient’s current condition stops him from doing what he wants and keeps him stuck in bed resting instead. My patient
Has kept his sense of humor and liveliness about im and firmly believes that he will come of this okay and be able to get
Back to his usual self.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
The patient states “I believe the cause is stress and my diet. Neither are very good for ones health,”.

What does your illness mean to you?

The patient states “It means a whole change of life for me,”.

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+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? __No__. 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?_ 30 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? The patient states that religion and spirituality is very important to
them.
Do your religious beliefs influence your current condition? The patient states that faith influences their current condition.

+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? 36 years
Cigarettes A pack a day (age 17 thru 53 )

If applicable, when did the

Pack Years: 36
patient quit? 5 years ago

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? No If yes, what did they use to try to quit? Quit cold turkey

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? 1 glass or can a week For how many years?
Beer & Wine Volume: Wine: 8 oz, Beer: 12 oz (age 18 thru 58 )
Frequency: Once a week
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
How much? Patient did not
Marijuana remember specifically but For how many years?
stated that it was not much
(age 18 thru 20 )

Is the patient currently using these drugs? If not, when did he/she quit? 20
Yes No years old

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks: The patient is a
construction worker and states that they are exposed to hazards daily when working on site. Hazards include dangerous
machinery, high heights, and lots of manual labor.

5. For Veterans: Have you had any kind of service related exposure? No

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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: 50 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? 2 years ago
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Due to fluids 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: A +
Post-nasal drip Normal frequency of urination: 6 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
Vision screening 1x year Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 4 years ago 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? no Depression
Hyperlipidemia Frequency of prostate exam? 1x year Schizophrenia
Chest pain / Angina Date of last prostate exam? Unknown Anxiety
Myocardial Infarction BPH- no Bipolar
CAD/PVD Urinary Retention- no Other:
CHF Musculoskeletal
Injuries or Fractures (broken bones
Murmur
from before)
Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever

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 Last EKG screening, when? This
Arthritis Chicken Pox
hospital visit
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs? 30 lbs
Time frame? 3 months
Intentional? No
How do you view your overall health? Fair

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: 177 cm Weight: 70.3 kg BMI: 22 Pain: (include rating and
is pleasant and Pulse: 78 bpm Blood Pressure: (include location): location)
cooperative, clean and Respirations: 18 132/84, Upper Right arm
neat, and has a strong 8/10: Back
family support system.
Temperature: (route SpO2: 96% Is the patient on Room Air or O2:
taken?) Oral, 36.7 % Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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

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

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

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
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: 22 g Location: L AC Date inserted: 10-16-16
Fluids infusing? no yes - what? D5/0.45S + KCC

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- 3 inches & left ear- 3 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Good, teeth are straight, not abnormally colored, patient does not report any pain or dentition problems.
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
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
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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: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: N/A pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date / / ) 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: Light Yellow Previous 24 hour output: 800
mLs 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 & ____5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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

CT: Abdomen 10/18/2016 -Pancreatic Lesion found

EGD/EUS w/ biopsy 10/19/2016 Results pending

WBCs 10/16-10/20 7.8 mcL (10/16), 5.6 The patients WBC counts
mcL (10/17), 7.1 mcL were normal and stable
(10/20) throughout multiple days
showing that there is no
infection present. There
was a slight drop in
counts but was picked up
a few days later.
RBCs 10/16-10/20 5.20 mil (10/16), 4.78 mil The patients RBC count
(10/17), 5.17 mil (10/20) lies in the normal and
stable stage for men. The
numbers are pretty
consistent and show no
serious abnormalities.
HgB 10/16-10/20 16.1 gm (10/16), 14.9 gm Patients hemoglobin
(10/17), 15.7 gm (10/20) levels are all stable and
clear and show that there
is enough oxygen in the
blood and circulating.
The patients numbers
stayed consistent and
there are no severe
problems.
Glucose 10/17, 10/20 112, 110 The patients glucose levels
were a little bit high but not
Platelets 10/16-10/20 279 k, 230 k, 286 k high enough to cause worry.
The patients glucose will
continue to be monitored
Hct 10/16-10/20 49.4 %, 45.6 %, 48 %
daily to be sure of any
changes.
The patients platelet counts
are good and stable and
show that the patient will
not have any problems
clotting if need be.
The patients hematocrit
levels are all in normal
range for men and there is

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 no need to worry about the
patients levels because they
are consistent.

+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: Patient is currently NPO due to the patient’s upcoming procedures that day. The patient would
otherwise follow a regular diet eating the same as if he were at home.
Vitals: The patient follows the regular assigned vital signs done every 6 hours. The patient has no need for
special vital signs like orthostatic VS or shorter intervals between sets of VS.
Activity: The patient is assigned activity as tolerated but is advised to not push it too much. The patient is
used to doing hard labor and lots of handy work but is taking the time to really relax.
Procedures: Patient is scheduled to have a splenectomy and pancreatectomy due to newly diagnosed
pancreatic cancer on the body of the pancreas.
Consults: Consults include oncology and surgical consults.
Accu Checks: Patient is assigned to have accu checks done regularly daily to monitor blood glucose levels
because levels have been a bit high.

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

1. Risk for infection related to impaired skin integrity (Post-operative incision sites).

2. Risk for impaired comfort related to post-operative pancreatectomy and splenectomy.

3. Anxiety related to newly diagnosed cancer as evidenced by the patient stating that they have new found anxiety over their
health.

4. Risk for constipation related to post-operative pain medications.

5. Fear related to surgeries as evidenced by patient stating they are slightly fearful of the scheduled surgeries.

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

± 15 CARE PLAN
Nursing Diagnosis: Risk for infection related to impaired skin integrity.
Patient Goals/Outcomes
1. The patient will remain
absent of any s/s of
infection including fever,
chills, edema on the site,
confusion, and weakness
during the stay in the
hospital.
2. The patient will
demonstrate appropriate
care of incision site
University of South Florida College of Nursing – Revision September 2014
Nursing Interventions to
Achieve Goal
1. The nurse will administer
any ordered antibiotics to
the patient to ensure
infection does not present
itself.
2. The nurse will perform
hand hygiene properly and
perform all necessary
safety precautions to
prevent the spread of
germs and infection.
1. The nurse will educate the
patient on the proper
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
1. Administering antibiotics - The goal will have been
as ordered allows the met if the patient remains
patient an extra line of free of the s/s of infection
defense against infections. during their stay in the
Post-operative patients are hospital.
at a high risk for infection
so antibiotics help
infections from not coming
around.
2. Washing hands with the
proper soup and for the
right amount of time
reduces the amount of
germs that are spread from
person to person. In the
hospital there are germs
everywhere and for the
safety of the patient and the
nurse it is vital that proper
hand hygiene is followed to
reduce the spread of germs
and infection in the
patients.
1. Having the patient know The goal will have been met if the
the proper techniques on patient can demonstrate
changing their bandages
16
 including proper dressing
changes and bandages by
the end of stay in the
hospital.
technique on dressing
changes and bandages.
2. The nurse will have the
patient demonstrate back to
them the proper technique
of dressing changes and the
s/s of site infections.
and dressings on their own appropriate care of the incision
will help to stop the spread sites.
of infection. The patient
will know how to clean,
change, and remain sterile
during the procedure.
2. Having the patient
demonstrate back to the
nurse ensures that they
have the proper knowledge
to keep infection away.

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 impaired comfort related to post-operative pancreatectomy and splenectomy.
Patient Goals/Outcomes
1. The patient will be able
to remain comfortable
after surgery during
their stay in the
hospital.
2. The patient will not
experience pain above
the level of 6 on a 0-10
pain scale by the end of
shift.
University of South Florida College of Nursing – Revision September 2014
Nursing Interventions to
Achieve Goal
1. The nurse will create a
calm, healing environment
for the patient by keeping
the lights low, no loud
noises, and limiting visitors
to allow the patient to rest.
2. The nurse will provide nice
distractions for the patient
like music, tv, reading, for
the patient to feel more
comfortable during their
stay in the hospital.
1. The nurse will
administer pain
medications as ordered
to relieve the patient’s
pain from surgery.
2. The nurse will apply
other non-pharma
logical ways to relieve
pain like ice and heat
to help the patient feel
more relaxed and
comfortable.
Rationale for Interventions Evaluation of Goal on Day Care
Provide References is Provided
1. By providing a calm 1. The goal will have
environment, the been met if the patient
patient will be able to is able to remain as
relax and heal more comfortable as possible
comfortably. Limiting after surgery during
noise, light, and many their stay in the
visitors keeps the hospital.
patient calm.
2. Providing small
distractions, such as
music or television
allows the patient to
feel more at home.
1. The goal will have been
1. By administering pain met if the patient does not
medicine as ordered, experience pain above the
the patient’s pain will level of a 6 on a 0-10 pain
be controlled at all scale by the end of the
times allowing the shift.
patient to heal more
comfortably.
2. Providing other
techniques of pain
relief offers the patient
more choices in how
their pain is managed.
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

McLeod, Saul (2013). Erik Erikson. Simply Psychology. Retrieved from

http://www.simplypsychology.org/Erik-Erikson.html#generativity

Hayes, Evelyn R., Kee, Joyce LeFever., McCuistion, Linda E. (2015). Pharmacology: A Patient-

Centered Nursing Process Approach. St. Louis, Missouri: Elsevier.

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

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