UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Bobby Vavlas

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 3/29/16

Agency: STJ

Patient Initials: F.S.

Age: 71 YO

Admission Date: 3/13/2016

Gender: Male

Marital Status: Not Married

Primary Medical Diagnosis: Hepatocellular

carcinoma with lung metastasis

Primary Language: English

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Military

Abdominal ascites

Number/ages children/siblings: No Siblings/ 1 daughter (55)

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

Code Status: Full Code

Living Arrangements: Pt lives alone in his apartment and has home

heath. He does live on the third floor but has an elevator to take him
up. Pt does need help with his ADL and home health helps him with
this and taking his meds, Pt is not fully dependent on home health
and is able to take care of himself for the most part.
Culture/ Ethnicity /Nationality: African American

Advanced Directives:
If no, do they want to fill them out? YES
Surgery Date: 3/14/2016
Procedure: Ultrasound guided paracentesis

Religion: Baptist

Type of Insurance: Medicare

1 CHIEF COMPLAINT: My stomach became really big and it felt like I had a lot of fluid building up. I
even checked my weight and saw that I gained a significant amount of weight in a short period of time. Then I began
having shortness of breath and difficulty breathing. I got scared cause I live alone so I came to the hospital and been

been here ever since.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Pt is a 71 YO African American male who presented to the ER on 3/13/2016 presenting with acute respiratory
insufficiency characterized as shortness of breath with dyspnea. He has a past medical history of metastatic cancer,
hypertension, COPD, asthma, and congestive heart failure. His last hospital admission was just a month ago. During that
hospitalization, he was diagnosed with metastatic cancer and was to follow up with oncology as an outpatient, however he
was unable to find transportation. Upon this admission he was found to be dyspneic and tachycardic with abdominal pain
to the RUQ. Blood work showed an increase of liver enzymes. CT of chest was performed and revealed increased
metastatic disease with ascites. CXR was also done and negative for infiltrates. The Pt was moved to 4N of St. Josephs
hospital on 3/13/16 and IV antibiotics, IV steroids, and nebulizers were started. CT of the abdomen was also done and
revealed a large mass expanding and replacing the entire left hepatic lobe with ascites. The Pt continued to complain of
abdominal pain that radiated to the left and on 3/14/16 an ultrasound guided paracentesis was done to remove the excess
fluid secondary to hepatic damage and portal hypertension. The pt is resting quietly on 4N and is on close monitoring and
was placed on tele. The Pt stated his shortness of breath and abdominal pain begin a week prior to this admission. The pt
stated that his pain is primarily in the RUQ and radiates to the LUQ. The patient stated that his pain is of sharp and
stabbing in nature. The pt also stated that nothing seems to relieve the pain or make it worse because it was constantly

University of South Florida College of Nursing Revision September 2014

there. The Pt also stated that his pain was an 8 out of 10. On 3/29/16 the pt is quietly resting in his room with no signs of
discomfort. The pt is on room air and does not have difficulty in breathing. The pt is not on any fluids and has a RFA 20
gauge 1 inch. The pt is ready to be discharged however is refusing hospice and the SNF. He does have home health and
discharge is pending.

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

Mother

81

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

N/A

76

Asthma

Sister

Father

Arthritis

Brother

Cause
of
Death
(if
applicable
)
Colon
cancer
MI (heart
attack)
N/A

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

As stated above

COPD: DuoNeb: 3 ml, NEB rtq6h ATC; Brovana 15 mcg= 2ml NEB rtq 12h;
Asthma: DuoNeb: 3 ml, NEB rtq6h ATC; fluticanasone 1 puff INH 2x daily; Atrovent 18 mcg/inh
inhalation aerosol: 2 puffs INH 4x daily
CHF: Furosemide 20 mg = 1 tab PO 2x daily; metoprolol 12.5 mg = .5 tabs PO 2x daily; DuoNeb: 3
ml, NEB rtq6h ATC
Lung Carcinoma: Oxycontin 20 mg = 1 tab PO q 12 hr; Tylenol 650 mg= 2 tabs PO q4hr, PRN: Pain
and fever; Zofran 4 mg = 2 ml IV q4hr, PRN nausea/ vomiting; Oxycodone 5 mg = 1 tab PO q4hr
PRN pain

Environmental
Allergies

As stated above

Operation or Illness
Hypertension: Furosemide 20 mg = 1 tab PO 2x daily; metoprolol12.5 mg = .5 tabs PO 2x daily;

Alcoholism

Date
Patient was unable
to recall specifics
and no date
assigned in chart.
As stated above
As stated above

relationship
relationship
relationship

Comments: Include age of onset: Besides causes of death and boxes that are checked, family for the most part is pretty healthy.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

University of South Florida College of Nursing Revision September 2014

NO
2

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) Date U
Adult Tetanus (Date) Is within 10 years? YES Date U
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA

Pt has no known allergies

NKA

Pt has no known allergies

Medications

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)
Cancer of the liver is a very prevalent disease in the United States in addition to being very prevalent world wide (Osborn,
Wraa, Watson, & Holleran, 2014). Liver cancer (LC) is the top three leading causes of cancer death
worldwide and is the fifth most common cause of cancer (Osborn et al., 2014). Some common causes of liver
cancer include viral infections of the liver which are associated with both acute and chronic manifestations and include hepatitis B and
hepatitis C (Osborn et al., 2014). Primary liver cancer is fairly rare in the United States and is seen much more often parts of
southeast Asia and Southern Africa (Osborn et al., 2014). Locally in the United States, primary LC is seen much more often in
our males of African American descent (Osborn et al., 2014). Primary LC is not usually seen in patients of younger age and
occurs in individuals when they reach about 60 years old (Osborn et al., 2014). Although LC may occur as a primary disease in
which the cancer has developed first in the liver, it most occurs secondary to metastasis from another organ (Osborn et al., 2014).
One of the livers many functions is to filter the blood of toxins which provides an excellent gateway of spreading cancer cells from
another organ directly to the liver. This is also known as secondary liver cancer. Both primary and secondary liver cancer account for a
very small percentage of deaths (3%) in the United States and death most often occurs from complications of liver failure (Osborn
et al., 2014).
There are two types of primary LC which include, hepatocellular and cholangiocellular (Osborn et al., 2014).
Hepatocellular carcinomas occur mainly in the liver cells themselves, also known as the hepatocytes, and take multiple forms
including nodular, massive (large tumors), and diffuse (small masses that are spread throughout the liver lobes) (Osborn et al.,
2014). When an individual is diagnosed with primary LC, they are also prone to developing other complications of the liver which
include chronic hepatitis and cirrhosis (Osborn et al., 2014). Due to the fact that the cancer spreads to the large hepatic and portal
veins, these patients are also prone to metastasis in other vital organs of the body including the brain, heart, and lungs (Osborn et
al., 2014). The second type of primary LC is called cholangiocellular carcinoma (Osborn et al., 2014). This type of LC begins
in the bile duct, where bile and pancreatic enzymes are secreted, and is found less often in the United States (Osborn et al., 2014).
Cholangiocellular carcinoma can be found in any part of the bile duct and is usually found isolated with only one lesion (Osborn et
al., 2014).
Patients who present with LC usually complain of vague abdominal symptoms which include nausea, vomiting, feeling very
full as if they had just eaten a meal, pressure placed on the diaphragm, and a dull ache in the right upper quadrant (Osborn et al.,

University of South Florida College of Nursing Revision September 2014

2014). Depending on how severe the LC is, it may present either slowly as the tumor enlarges or abruptly (Osborn et al., 2014).
A very common manifestation of chronic LC is cirrhosis of the liver (Osborn et al., 2014). If an individual develops cirrhosis
their liver that was once a soft sponge like mass, able to absorb and easily collect and distribute blood, becomes sclerotic and rock like
in which all of its function becomes diminished (Osborn et al., 2014). Due to the sclerotic changes the liver it is unable to easily
pass and filter blood, which results in a decrease of blood perfusion to vital organs in addition to and back up and increase in pressure
in the portal vein known as portal hypertension (Osborn et al., 2014). As the portal hypertension increases and the pressure
begins to accumulate and grow larger and larger the kidneys do not get the blood perfusion that they need and release aldosterone
which increase salt and water reabsorption in the body (Osborn et al., 2014). As more and more fluid accumulates this increases
the portal hypertension and causes the fluid to leak out or third space into body cavities leading to a condition known as ascites
(Osborn et al., 2014). Ascites presents with a large amount of fluid in the abdomen, leading to abdominal distention and dyspnea
in the patient (Osborn et al., 2014). Another important function of the liver is to produce albumin, a protein which causes fluid to
move into the vasculature (Osborn et al., 2014). Due to the low levels of albumin caused by liver failure and the portal
hypertension, many patients who develop liver failure will develop ascites (Osborn et al., 2014). In addition to ascites, patients
who develop cirrhosis from LC will also develop jaundice and a lack of apatite due to abdominal distention (Osborn et al., 2014).
Cholangiocellular carcinoma more often is shown to present with pain, loss of apatite, weight loss, and jaundice than hepatocellular
carcinoma (Osborn et al., 2014).
Diagnosis for LC is based on the patients history, physical exam, laboratory findings, various radiological imaging, and
biopsy findings (Osborn et al., 2014). Cat scans or ultrasounds are used to find the solid tumors, however neither of these
techniques are able to decipher whether the tumor is benign or cancerous (Osborn et al., 2014). Primary prevention techniques
include prevention of the virus which causes hepatitis B and C, and this is done by vaccination, screening donated blood, and
providing teaching on medications that are commonly used over the counter which are hepatotoxic (Osborn et al., 2014). Surgical
removal of the tumor is also a possibility for treatment if the tumor is able to be removed without causing further complications
(Osborn et al., 2014). However, this is very tricky because patients in liver failure do not have a high amount of platelets and
bleeding is a major complication (Osborn et al., 2014). Chemotherapy agents may also be administered for treatment however
many have very nasty side effects (Osborn et al., 2014). Liver transplant offers another promising treatment if the supply is
available and gene therapy and immunotherapy are being looked at (Osborn et al., 2014). The prognosis for patients who are
diagnosed with LC is very poor and most do not make it past 5 years (Osborn et al., 2014).
References:
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing:
Preparation for practice (2nd ed.). Upper Saddle River, N.J.: Pearson Prentice Hall.

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: Furosemide (Lasix)

Concentration: 20 mg = 1 tab

Route: PO

Dosage Amount: 20 mg

Frequency: 2xdaily

Pharmaceutical class: Loop diuretics

Home

Hospital

or

Both

Indication: Used to treat patients fluid volume overload due to HF, also used to aid in the treatment of the patients hypertension.
Adverse/ Side effects: dizziness, drowsiness, lethargy, weakness, hypotension, anorexia, cramping, hepatitis, nausea, vomiting, Stevens Johnson Syndrome,
photosensitivity, rash, acute angle-closure glaucoma, acute myopia, hyperglycemia, hypokalemia, dehydration, hypocalcemia, hypochloremic alkalosis,
hypomagnesaemia, hyponatremia, hypovolemia, blood dyscrasiasis, byperuricemia, hypercholesterolemia, muscle cramps, pancreatitis. NSAIDS may decrease
effectiveness, hypokalemia increase risk of digoxin, decrease the excretion of lithium.
Nursing considerations/ Patient Teaching: Monitor BP, intake, output, and daily weights and assess feet, legs, and sacral area for edema daily; if hypokalemia
occurs consideration may be given to potassium supplementation or decrease dose of diuretic; assess patient for allergy to sulfonamides. Instruct patient to take
this med at the same time each day; instruct patient to monitor weight biweekly and notify the health care provider of significant changes; caution patient to
change position slowly to minimize orthostatic hypotension; advise patient to wear sunscreen and protective clothing when going outdoors.
Name: Ondansetron (Zofran)

Concentration: 4 mg = 2 mL

Route: IV

Dosage Amount: 2 mL

Frequency: q4hr PRN

Pharmaceutical class: Five ht3 antagonist

Home

Hospital

or

Both

Indication: Used for patients nausea and vomiting as needed

Adverse/ Side effects: headache, dizziness, drowsiness, fatigue, weakness, Torsade De Pointes, QT interval prolongation, constipation, diarrhea, abdominal pain,
dry mouth, increased liver enzymes, extrapyramidal reactions. Use with amorphine increased risk of severe hypotension and loss of consciousness; concurrent
use contraindicated; carbamazepine, phenytoin, and rifampin may decrease levels.
Nursing considerations/ Patient Teaching: assess patient for nausea, vomiting, abdominal distention, and bowel sounds prior to and following administration,
assess patient for extrapyramidal effects periodically during therapy; instruct patient to take Zofran as directed; advise patient to notify provider immediately if
symptoms of irregular heart beat or involuntary movement of eyes, face, or limbs occur.
Name: fluticasone (Flovent HFA)

Concentration: 250 mcg-50 mcg inhaler

Route: Nasal spray

Dosage Amount: 50 mcg inhaler

Frequency: 2xdaily

Pharmaceutical class: Corticosteroids

Home

Hospital

or

Both

Indication: Used for patients asthma

Adverse/ Side effects: Headache, dizziness, dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis, bronchospasm, cough,
upper respiratory tract infection, wheezing diarrhea, adrenal suppression, decrease bone mineral density, decrease growth in children, Cushings syndrome,
muscle pain, hypersensitivity reactions including: anaphalaxis, laryngeal edema, urticarial, bronchospasm, Churg-Strauss Syndrome, fever.
Nursing considerations/ Patient Teaching: monitor respiratory status and lung sounds; assess pulmonary function test periodically during and for several
months after a transfer from systemic to inhalation corticosteroids; assess patients changing from systemic corticosteroids to inhalation ones for signs of adrenal
insufficiency (anorexia, nausea, weakness, fatigue, hypotension, hypoglycemia) during initial therapy and periods of stress. If these signs appear, notify health
provider immediately; monitor for withdrawal symptoms; monitor growth rate in children receive chronic therapy, use lowest does possible; may cause
decreased bone mineral density during prolonged therapy; monitor for signs of hypersensitivity reaction. Advise patients to take dose as directed; advise
patients using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to elapse before administering the corticosteroid;
advise patient to stop using medication and notify provider immediately if signs and symptoms of hypersensitivity reactions occur; caution patient to avoid
smoking, known allergies, and other respiratory irritants; advise patient to notify provider if sore throat or mouth occurs; teach female patients to notify
provider if pregnancy is planned or suspected or if breastfeeding.
Name: Toprol- XL (metoptolol)

Concentration: 12.5 mg = 0.5 tab

Route: PO

Dosage Amount: 12.5 mg

Frequency: 2 xdaily

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: used for treatment of patients HF and helps with the patients hypertension
Adverse/ Side effects: fatigue, weakness, anxiety, depression, dizziness, drowsiness, insomnia, memory loss, blurred vision, stuffy nose, bronchospasm, wheezing,
bradycardia, HF, pulmonary edema, hypotension, peripheral vasoconstriction, constipation, diarrhea, dry mouth, flatulence, ED, decreased libido, rashes,
hyperglycemia, hypoglycemia, joint pain.
Nursing considerations/ Patient Teaching: abrupt withdrawal may precipitate life threatening arrhythmias, hypertension, or myocardial ischemia; teach patient
and family how to check pulse daily and BP biweekly and to report significant changes to health care professional, may cause drowsiness caution patient to
avoid operating any vehicles; advise patient to change positions slowly; diabetics should closely monitor blood glucose especially if weakness, malaise,
irritability, or fatigue occurs; advise patient to notify health care provider if slow pulse, difficulty breathing, wheezing, cold hands, dizziness, confusion,
depression, rash, sore throat, or unusual bleeding occurs. Take apical pulse before administering if <50 bpm withhold medication.

University of South Florida College of Nursing Revision September 2014

Name: Tylenol (acetaminophen)

Concentration: 650 mg = 2 tabs

Route: PO

Dosage Amount: 650 mg

Frequency: q4hr PRN

Pharmaceutical class: nonopiod analgesic

Home

Hospital

or

Both

Indication: used to treat patients pain from cancer

Adverse/ Side effects: hypertension (IV), hypotension (IV), hepatotoxicity, constipation, increased liver enzymes, nausea, vomiting, hypokalemia, renal failure,
neutropenia, pancytopenia, muscle spasms, steven Johnson syndrome, toxic epidermal necrolysis, rash, uriticaria,
Nursing considerations/ Patient Teaching: Assess for rash periodically during therapy may cause Steven Johnson syndrome discontinue therapy if rash, or
accompanied with fever fatigue, muscle or joint aches, oral lesions. Assess pain type and location prior to and 30-60 min following administration, chronic
excessive use of >4g/day may lead to hepatotoxicity, renal or cardiac damage; advise patient to avoid alcohol 3 or more glasses per day this increases the risk for
liver damage, advise patient to discontinue medication and notify health care professional if rash occurs.
Name: DuoNeb

Concentration: 3 mL

Route: NEB

Dosage Amount: 3 mL
Frequency: rtq6h ATC

Pharmaceutical class: adrenergics

Home

Hospital

or

Both

Indication: Used for patient shortness of breath due to HF also used for COPD and asthma
Adverse/ Side effects: nervousness, restlessness, tremor, headache, insomnia, hyperactivity in children, paradoxical bronchospasms, chest pain, palpitations,
angina, nausea/vomiting, hyperglycemia, hypokalemia.
Nursing considerations/ Patient Teaching: assess lung sounds, pulse BP, before administering and during peak of medication, monitor pulmonary function tests
before initiatring therapy and periodically during therapy; observe for paradoxical bronchospasm (wheezing), instruct patient to watch for bronchospasm that
is likely on first dose; instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication; instruct patient to
prime unit with 4 sprays before using and to discard canister after 200 sprays.
Name Atrovent (Ipratropium)

Concentration: 18 mcg/inh

Route: Inhalation aerosol

Pharmaceutical class: anticholinergics

Dosage Amount: 18 mcg 2 puffs

Frequency: 4x daily
Home

Hospital

or

Both

Indication: Used to treat pts asthma

Adverse/ Side effects: dizziness, headache, nervousness, blurred vision, sore throat, bronchospasm, cough, hypotension, palpitations, GI irritation, nausea, rash
Nursing considerations/ Patient Teaching: assess respiratory status before administration and at peak of medication. Consult health care professional about
alternative medication if severe bronchospasm is present. If paradoxical bronchospasm occurs, withhold, medication and notify the health care provider.
Instruct patient in proper use of the inhaler, nebulizer and nasal spray, and to take medication as directed. Take missed dose as soon as rememebered unless its
too close to the next dose. Caution patient not to exceed 12 doses within 24 hours. Caution pt to avoid spraying medication in eyes may cause blurry vision or
irritation. Advise pt to notify health care provider if cough, nervousness, headache, dizziness, nausea, or GI distress occurs.
Name: Oxycontin

Concentration 20 mg= 1 tab

Route PO

Dosage Amount 20 mg

Frequency: q12hr

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: Used for pts pain related to cancer

Adverse/ Side effects: blurred vision, diplopia, miosis, respiratory depression, orthostatic hypotension, constipation, dry mouth, GI obstruction, nausea,
vomiting, urinary retention, flushing seating, physical dependence, tolerance.
Nursing considerations/ Patient Teaching: asses oldcarts pain prior to and and 1 hr peak after administration. Assess BP, pulse, and respirations before and
periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25-50%. Initial drowsiness will
diminish with continued use. Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent the pt from receiving
adequate analgesia. Assess bowl function routinely as these drugs do cause constipation. Instruct patient on how and when to ask for pain medication. Advise pt
that this drug is one with known abuse potential. Protect it from theft, and never give to anyone other than whom it was prescribed to. Medication may cause
drowsiness and dizziness, advise pt to call for assistance before ambulation. Avoid driving and using heavy machinery when using this drug. Advise patient to
make position changes very slowly to prevent orthostatic hypotension. Encourage pt to turn cough and deep breath to prevent atelectasis.

University of South Florida College of Nursing Revision September 2014

Name oxycodone

Concentration: 5 mg= 1 tab

Route PO

Dosage Amount 5 mg

Frequency q 4hr PRN

Pharmaceutical class: opioid agonist

Home

Hospital

or

Both

Indication: used for pts pain related to cancer

Adverse/ Side effects: blurred vision, diplopia, miosis, respiratory depression, orthostatic hypotension, constipation, dry mouth, GI obstruction, nausea,
vomiting, urinary retention, flushing seating, physical dependence, tolerance.
Nursing considerations/ Patient Teaching: asses oldcarts pain prior to and and 1 hr peak after administration. Assess BP, pulse, and respirations before and
periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25-50%. Initial drowsiness will
diminish with continued use. Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent the pt from receiving
adequate analgesia. Assess bowl function routinely as these drugs do cause constipation. Instruct patient on how and when to ask for pain medication. Advise pt
that this drug is one with known abuse potential. Protect it from theft, and never give to anyone other than whom it was prescribed to. Medication may cause
drowsiness and dizziness, advise pt to call for assistance before ambulation. Avoid driving and using heavy machinery when using this drug. Advise patient to
make position changes very slowly to prevent orthostatic hypotension. Encourage pt to turn cough and deep breath to prevent atelectasis.
Name: Brovana

Concentration: 15 mcg = 2 ml

Route: Neb inhalation

Dosage Amount 2 ml

Frequency: rtq 12hr

Pharmaceutical class: adrenergics

Home

Hospital

or

Both

Indication: Used to treat bronchospasm associated with pts COPD

Adverse/ Side effects: headache, insomnia, nervousness. Weakness, asthma related death, paradoxical bronchospasm, ECG changes, tachycardia, vomiting,
rash, hypokalemia, leukocytosis, cramps, tremor, hypersensitivity reactions, fever.
Nursing considerations/ Patient Teaching: assess lung sounds, pulse, and BP before administration and periodically during therapy. Monitor pulmonary
function tests before initiating therapy and periodically during therapy to determine effectiveness of medication. Observe for paradoxical bronchospasm and
hypersensitivity reaction. Inform patient that this medication may increase the risk of asthma related death, inform pt who have been taking beta 2 agonsist
regularly to discontinue use and use only for symptomatic relief. Advise pt to notify health care professional immediately if difficulty in breathing persists after
use, if condition worsens, or if more of the medication is used to decrease the attack. Advise female pts to notify health care professional if pregnancy is planned
or suspected or if breast feeding.

References
Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (n.d.). Unbound Medicine, Inc. [Software]. Daviss Drug Guide.
Nursing Central. Retrieved from http://www.unboundmedicine.com/products/nursing_central

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? Regular diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular diet Pt states he eats Consider co-morbidities and cultural considerations):
anything he wants at home bevcause he doesnt have
anyone to answer to.
24 HR average home diet:
Analysis of Home diet
Breakfast: Patient states that in the morning he eats/drinks 1 After analyzing my patients diet and comparing it to my
plate I would highly recommend some major modifications
mug of coffee (8 fl ounces) black with no cream, 2
to his diet. To start, my patient isnt getting the
blueberry waffles (4 inch squares), 2 tablespoons of syrup,
recommended percent of daily vegetables and protein that
1 tablespoon of butter (I cant believe its not butter) and 2
his body needs. Due to the fact that my patient was
regular slices of white bread with 1 tablespoon of grape
diagnosed with cancer he is body needs all the nutrition that
jam.
he can get. His body is already immunosuppressed and by
not getting the appropriate amount of protein for recovery
Lunch: Patients states that for lunch he typically
and a good source of vitamins and minerals from the
eats/drinks 1 medium fast food order of French fries from
Burger King, 1 cheeseburger with 1 tablespoon mayonnaise vegetables, he is only doing a major disservice to his body.
1 tablespoon catsup and tomato on a bun from Burger King Although he was not getting the appropriate amount of
(whopper jr), 1 medium coke (22 fl ounces), and a small ice nutrients, what truly amazed me wash how much salt he
was consuming. Due to his ascites, I would definitely
cream cone.
recommend decreasing his salt intake because as the saying
goes where salt goes water flows. This will help him with
Dinner: Patient states for dinner he typically eats a steak
his difficulty in breathing as well because it would decrease
and cheese sub on a white roll with 1 tablespoon of
his abdominal distention from the accumulation of fluid,
mayonnaise, a small order of french fries, and a 12 ounce
which in turn will place less pressure on his lungs and
bottle of beer.
diaphragm. I would also recommend that the pt follow and
strict salt restricted diet instead of a regular diet to decrease
Snacks: Patient states that he loves to eat a single serving
that volume overload. I would also recommend he add
size bag (1 oz) of Cheetos for a snack.
more fruits and vegetables and protein to his diet and stay
away from the salty fast foods. I was very confused as to
Liquids (include alcohol): water, coca cola, coconut milk,
why this patient was placed on a regular diet at the hospital
beer with dinner (corona).
as well and I would advocate for my patient and place him
on a cardiac or salt restricted diet.

References
United States Department of Agriculture. (2016). SuperTracker. United States Department of Agriculture.
Retrieved from https://www.supertracker.usda.gov

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 home health nurse and team help me when I am ill. I dont have any family
members that can help me and my daughter past, so I am all alone. Thank God I have the home health care team.
How do you generally cope with stress? or What do you do when you are upset? When I am upset or stressed I like
to look at past pictures of me and my daughter. I also like to look back at pictures of me in the military which reminds me
of the good old time.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): My only
recent difficulty was coming into the hospital and being here for so long. I am feeling sort of down because I dont want to
be here anymore, but I also dont want to go to hospice.
+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 never.
Have you ever been talked down to? Nope. Have you ever been hit punched or slapped? In the military we would
always fight but we would make up after.
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? Im not in a relationship right now. But I am safe.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

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

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Integrity vs Despair is the final stage of Ericksons stages of psychosocial development. This

stage occurs when an individual reaches the later parts of their lives and is characterized as being over the age
of 65 until death. In this stage the individual begins to reminisce on their life and come away with either a sense
of Integrity or a sense of despair. Those who have truly believed they have lived a beautiful life full with
excitement and no regrets will come away with a sense of integrity, gain wisdom and welcome with open arms
the next chapter in life which is death. Those individuals who look back onto their lives and are filled with
regret because they feel as if they did not do everything they wanted to do and are not satisfied will leave with a
sense of despair.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The stage my patient is in is the Despair stage. My patient stated I really wish I didnt have all of these diseases I feel
like I didnt live my life they way I should of. I went into the army because thats all I knew how to do. I met a girl had a
baby and never even married her. I also didnt have a great relationship with my daughter when she passed and now this is
all I have to show for it, nothing. My patient is clearly in the despair stage and in my opinion has a lot of regret in the
way he lived his life. I believe if my patient was able to and given the chance he would go back in his life and change it. I
feel very bad for him and hopefully he will be at peace with himself. By his words and actions my patient is in the despair

University of South Florida College of Nursing Revision September 2014

stage.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patient described the same sorrow of his most recent hospitalization. My patient stated I hate cancer and its ruining my life, all
the time I though I had to live before this new diagnoses is short and there is no way I could live a fulfilling life like this and make up
for my mistakes. This patients recent hospitalization has only worsen and added to his developmental stage of life of despair. I truly
believe he would like to make up for his mistakes and relive the rest of his life without regret but I believe this will only damper his
spirits.

References
Cherry, K. (n.d.). Generativity Versus Stagnation. About Psychology. Retrieved from

http://psychology.about.com/od/psychosocialtheories/a/integrity-versus-despair.htm
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I believe I caused my illness. I never did the right thing, and I only looked out for my self. Maybe this is a way of God
telling me something.
What does your illness mean to you?
My illness is actually very important to me. It has made me realize a lot about myself and made me regret a lot. Even
though I have other illnesses, this is the one that means the most.

+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? Oh yes, Many times.
Do you prefer women, men or both genders? Women of course!
Are you aware of ever having a sexually transmitted infection? I hope not, I am pretty clean.
Have you or a partner ever had an abnormal pap smear? NA
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? Haha yes.
If yes, are you in a monogamous relationship? NO.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? I always wear a condom.
How long have you been with your current partner? I dont have one.
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?
Religion is a huge part of my life. Without it you got nothing to live for.
Do your religious beliefs influence your current condition? Yes I believe God is trying to tell me something.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? X 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? NO

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?
Yes
What? Beer
How much? 12 pack per week
Volume: 144 ounces per week
Frequency: 1x per week
If applicable, when did the patient quit?
3 years ago

No
For how many years?
(age 17

thru

68

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
NO.
5. For Veterans: Have you had any kind of service related exposure? Yes I worked on the machines a lot so I guess all the
fumes from that.

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 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen NO
SPF:
Bathing routine: 2x per day
Other:

Be sure to answer the highlighted area

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

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? 5 years ago
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: N/A
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 7
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2 x/day
x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 3/13/16
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

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?
Date of last prostate exam? Could not
give
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
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

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Last EKG screening, when? 3/13/16

Other:

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs? 5 pounds
Time frame? 1 weeks
Intentional? No ascites
How do you view your overall health? Not good, I am a mess.

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: Pt is a
Height 5 11
Weight 160
BMI
Pain: (include rating and
71 YO male who is thin
location)
Pulse 114
Blood Pressure: (include location)
and frail and as of now
127/81
brachial
pulse
Respirations 16
shows some signs of
8/10 Mostly in the LUQ
distress due to pain
radiates to RUQ
Temperature: (route
SpO2 99%
Is the patient on Room Air or O2
taken?) 98.5 sublingual
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: Peripheral IV
Location: RFA
Date inserted: 3/27/16
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- 7
inches & left ear- 7
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: yellow need cleaning
Comments: sclera tint of yellow (jaundice)
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
AP ration slightly distended 1:1
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 CR
RLL CR

Chest expansion

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

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3
Carotid: 3
Brachial: 3
Radial: 3
Femoral: 3
Popliteal: 3
DP: 3
PT:3
No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
none
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly: Liver enlarged
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date 3
/ 28
/ 16
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown clay colored 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: Liver was enlarged upon percussion of abdomen there was fluid and a dull sound was heard abdomen
was tender to touch especially in the RUQ
GU
Urine output:
Clear
Cloudy
Color: straw colored
Previous 24 hour output:
N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

mLs

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __4_____ RUE __4_____ LUE ___4____ RLE 4 & ___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
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: 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
AST

Dates

524
584
650
708

3/25/16
3/26/16
3/27/16
4/3/2016

Trend
The pts AST levels are
trending upwards.

(normal 7-37)

ALT
95
203
277

The pts ALT level are

trending upwards.
3/25/16
3/26/16
4/3/16

(normal 12-78)
Albumin
3
2.9
3.1
3.2

The pts albumin level are

trending downward.
3/25/16
3/26/16
3/27/16
4/3/2016

(normal 3.5-5.5)

Billirubin
.4

The pts billi is trending

upward
3/25/16

Analysis
The pts AST levels are
very high and well above
the normal range. AST is
one of the liver enzymes
that is secreted during
acute and possible
chronic liver damage.
This indicates that his
liver is being damaged
due to the cancer and may
possibly reach failure.
The pts ALT level are also
significantly high. ALT is
the other liver enzyme
that is released by the
liver and is used to detect
the level of injury and
function of the liver. This
indicates that the pts liver
is being damaged.
The pts albumin levels
are lower than the normal
range. Albumin is a
protein that is made in the
liver and when the liver
fails or becomes sclerotic
or damaged due to liver
cancer albumin
production is decreased.
Albumins main function
is to keep fluid within the
vasculature. This is the
cause of the pts ascites.
Billirubin is a byproduct
of the breakdown of red
blood cells that is

University of South Florida College of Nursing Revision September 2014

16

.6
.6
.8

3/26/16
3/27/16
4/3/2016

(normal .3-1.9)

excreted through the liver.

The pts serum billi is
trending upward which
indicates the pts liver is
beginning to decrease
processing this bilirubin
from the blood which
indicates liver failure and
may be the reason for his
icteric color.

Ultrasound guided paracentesis ( 3/14/16): a total of 400 ml of serosanguinous fluid was removed and sent to the
lab for analysis. No complications of bleeding or perforation.
ECG (3/13/16): Normal sinus rhythm
CT abdomen and pelvis without contrast (3/20/16): large mass expanding and replacing the entire left hepatic
lobe. There is some ascites.
Chest 1 view (3/13/16): no pleural effusion or pneumothorax. Pulmonary and mediastinal masses.

+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 should have their vitals q4hours. Patient should be given oxygen via nasal cannula at 2L/minute when dyspnea
secondary to ascites occurs. The patient was ordered a regular diet however should be placed on a salt restricted diet to
avoid fluid volume overload. Pt has bathroom privileges with no assistance. Pt was placed on DVT prophylaxis. Pt was
placed on tele for close monitoring of heart rate and other vitals. The patient was ordered to follow up with his PCP in one
week, pulmonology in one week, and oncologist ASAP for new diagnosis. Pt should also follow up with palliative to
manage pts pain.

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

1. Impaired gas exchange related to liver cancer as evidence by abdominal ascites
2. Decreased cardiac output related to liver cancer (sclerotic liver) as evidence by portal hypertension and abdominal ascites
3. Excessive fluid volume related to liver cancer as evidence by abdominal ascites
4. Risk for infection related to liver cancer as evidence by having third spacing in abdominal cavity
5. Acute pain related to liver cancer as evidence by the pt stated My pain is an 8 out of 10.
6. Decreased mobility related to liver cancer as evidence by the pt stated My pain hurts when I move around and I have
trouble breathing.
7. Ineffective coping related to liver cancer as evidence by new diagnoses and the pt stated even though I had all those
other illnesses this is the one that really got me.
8. Decreased readiness to learn related to pain and new diagnoses as evidence by the pt stated My pain is an 8 out of 10.
9. Knowledge deficit related to new diagnoses as evidence by the pt eating a regular diet instead of a salt restricted diet.

University of South Florida College of Nursing Revision September 2014

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 15 CARE PLAN
Nursing Diagnosis: Ineffective coping related to liver cancer as evidence by new diagnoses and the pt stated even though I had all those other illnesses this is
the one that really got me.

Patient Goals/Outcomes
Patient will use effective coping
strategies

Nursing Interventions to Achieve

Goal
Encourage the client to describe
previous stressors and the coping
mechanism used.
Patient will verbalize his strengths
and self worth.

Rationale for Interventions

Evaluation of Goal on Day Care
Provide References
is Provided
A study was done that saw that a
Goal was met pt verbalized to me
psychoeducational intervention
what ways he coped with previous
which included both encouraging
stressors that were beneficial.
the client to identify previous
stressors and what coping
mechanisms they used significantly
improved PTSD and depression
(Ackley & Ladwig, 2014)

One study suggests that by

identifying the patients strength
he/she will see their self value and
enhance resources for coping
(Ackley & Ladwig, 2014)

Remain free of destructive

behavior toward self or others

Use verbal and nonverbal

therapeutic communication
approaches like active listening and
confrontation to encourage the
client to express emotions.

The clinicians communication

skills greatly reduce anxiety and
hostile behavior and contribute to
the well being of the client (Ackley

Goal was met therapeutic

communication was done and the
client successfully expressed his
concerns and feelings

& Ladwig, 2014)

Provide opportunities for the client In a review that examined the

to discuss the meaning the situation characteristics of coping with
cancer in adults several factors
may have to the client
were identified which included the
client having the chance to create
their meaning (Ackley & Ladwig,
2014)

Report decrease of physical

symptoms of stress

Provide fun physical and mental

activities within the clients ability

Researchers found that

involvement of enjoyable activities

University of South Florida College of Nursing Revision September 2014

Goal was met patients physical

symptoms of stress were decreased
19

(watch TV, read a book, walk

around the unit).

physically reduced stress in

patients suffered from fatal
diagnoses( Ackley & Ladwig, 2014).

Encourage the use of spiritual

resources as desired

Spiritual activities such as prayer

was shown to greatly reduce the
stress of living with HIV in a group
of Thai women (Ackley & Ladwig,
2014)

Long Term Goal: Patient will come

to terms with his new diagnoses
and live a happy and fulfilling rest
of his life with no suicidal ideation
or self harm.

Pt will come to terms with his

diagnoses by speaking to others in
a community setting in hopes to
share his story and benefit others
with fatal diagnoses.

Patients may use self harming

behaviors as a means of
communication or way of coping

Goal was not met. Pt was not

discharged yet and it was the end of
my shift.

(Ackley & Ladwig, 2014)

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 patients medications available at a discount pharmacy? Yes No
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Rehab/ HH
Palliative Care

Nursing Diagnosis: Excessive fluid volume related to liver cancer as evidence by abdominal ascites
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on Day
Achieve Goal
Provide References
Care is Provided
Maintain body weight appropriate
for the client

Weigh the patient daily at the same

time of day (morning) with the
same amount of clothes on and
with the same scale.

By measuring the patients weight

daily, it is an excellent way to
monitor fluid volume (Ackley &

Monitor intake and output have

strict regulation on intake and
output

Accurately measuring the intake

and output of the client is an
important intervention especially
with fluid overload to make sure
there not taking in additional fluids
that can cause additional problems

Goal was met pt weighed the same

before and after my shift

Ladwig, 2014)

(Ackley & Ladwig, 2014)

Maintain clear lung sounds with no

evidence of dyspnea and orthopnea

Listen to lung sounds for crackles,

monitor respirations for effort, and
determine the presence and
severity of orthopnea

Acute pulmonary edema may be

due to increased permeability of
the alveolar and capillary
membrane which may present with
crackles upon auscultation (Ackley

Goal was not met crackles were

observed in the lower lung fields.

& Ladwig, 2014)

Remain free of edema, effusion,

and anasarca

Increase the patients mobility and

encourage techniques of turn,
cough, and deep breath in addition
to IS to clear and mobilize
secretions.

It has been proven in many studies

that mobilization and IS techniques
decrease atelectasis and promote
lung expansion and clearing of
secretions (Ackley & Ladwig, 2014)

Monitor serum and urine

osmolality, serum sodium, and

In a patient with fluid volume

overload these lab values will be

University of South Florida College of Nursing Revision September 2014

Goal was met the pt remained free

of edema, effusion, and anasarca.
21

BUN/Creatinine ratio, and

hematocrit for abnormalities.

able to give a good inclination on

fluid status of the patient (Ackley &
Ladwig, 2014)

Long term goal: Pt will be

compliant with medications long
term to manage fluid volume
excess

Provide a restricted sodium diet as

appropriate if ordered

Restricting the sodium in the diet

will favor the renal excretion of
excess fluid (Ackley & Ladwig, 2014)

Education will be provided with re

demonstration and assessment of
the clients knowledge of when,
how, and why the patient is taking
each medication prior to discharge.

In a study done it was shown that

many older individuals suffer from
polypharmacy and have multiple
medications that they are not
compliant with (Ackley & Ladwig,

Goal was not me pt was not

discharged and my shift ended

2014)

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:

SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References

Ackley, B., Ladwig, G. (Ed. 10). (2014). Nursing Diagnosis Handbook An Evidence-Based Guide to Planning
Care. St. Louis, Missouri: Elsevier

Mosby.

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