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COLLEGE OF NURSING
Student: Kimone Wright
Assignment Date: January 23, 2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital of Tampa
1 PATIENT INFORMATION
Patient Initials: H.R. Age: 82 Admission Date: February 22, 2016
Gender: Male Marital Status: Married Primary Medical Diagnosis:
Bladder cancer
Primary Language: English
Level of Education: Bachelors Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Electrical Engineer
Number/ages children/siblings:
2 children ages 40 (daughter) and 44 (son)
1 brother age 78
1 CHIEF COMPLAINT:
Transurethral Resection of the Prostate (TURP)/ Bladder tumor
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is an 82-year-old gentleman who was admitted on February 22, 2016 for a resection of bladder tumor. On
April 23, 2015, the patient was brought in for the same problem and had a resection done on that said date. Results
showed low-grade papillary tumor with superficial submucosal involvement. However, in December, the patient had a
cystoscopy which showed the recurrent tumor on the base of his bladder, the bladder neck, and on to the prostatic fossa.
Previous retrograde was done on the left that showed J hooking, but a retrograde was not done on the right side. The
patient has been on warfarin and aspirin, which had been stopped 5 days prior to the surgery.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
University of South Florida College of Nursing Revision September 2014 1
Date Operation or Illness
02/22/16 Cystoscopy/TUR Bladder Tumor: Resection of the bladder tumor with transurethral resection of the
prostate
02/22/16 Cystoscopy/Retrograde Pyelogram: Resection of the bladder tumor with transurethral resection of the
prostate
04/23/15 Cystoscopy/TUR Bladder Tumor: Bilateral retrograde pyelogram attempted, transurethral bladder
tumor
06/27/13 Thoracoscopy/Thoractomy-Robotics: Robotic Right Upper Lobectomy with Mediastinal Lymph
Node Dissection
05/28/13 Inguinal/Groin Exploration: Evacuation and drainage of right groin seroma
Age (in years)
Kidney Problems
Environmental
Trouble
Health
Stomach Ulcers
Bleeds Easily
Hypertension
Cause
etc.)
FAMILY
Alcoholism
Glaucoma
Diabetes
Arthritis
Seizures
Anemia
Asthma
of
Cancer
Tumor
Problems
Stroke
Allergies
MI, DVT
MEDICAL
Gout
Death
Mental
Heart
HISTORY (if
(angina,
applicabl
e)
Father
Mother
Brother
Sister
relationship
relationship
relationship
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? 4 years
Influenza (flu) (Date) Is within 1 years? Last year
Pneumococcal (pneumonia) (Date) Is within 5 years? N/A
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
Medications
None N/A
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)
Bladder cancer occurs more frequently in older adults over the age of 65. Bladder tumors are four times more
common in men than in women; it is the fourth most common cancer in men, and the ninth most common cause of death
by cancer in men (Osborn, Wraa, Watson, & Holleran, 2014). There are three main categories of tumors: supervision
noninvasive, invasive into underlying muscles, and metastatic, however, approximately 90% of bladder tumors are
transitional cell carcinomas that arise from the transitional epithelium of mucous membranes (Osborn et al., 2014). Bladder
tumors may develop on the surface of the bladder wall or within the wall. There are a number of risk factors that
contribute to primary bladder cancer. The risk is greater among people who smoke (approximately 50% of those
diagnosed with bladder cancer are smokers) or are exposed to metabolites of aniline dyes, beta naphthylamine, and
benzidine (Osborn et al., 2014). However, other risk factors may include artificial sweeteners, nitrates, and exposure to
certain chemotherapeutic agents.
According to Huether and McCance, the first sign of bladder tumor is most commonly gross, painless,
intermittent hematuria, often accompanied by lower urinary tract symptoms, including daytime voiding frequency,
nocturia, urgency, and urge urinary incontinence. Huether and McCance continued to say that flank pain may occur if
tumor growth obstructs one or both ureterovesical junctions. Patients with bladder tumor may also present with signs of
urinary tract infection or an actual infection. Cancer may spread to other sites in the body by metastasis. Metastasis of
bladder cancer is usually to lymph nodes, liver, or lungs. Also, secondary bladder cancer develops by invasion of cancer
from bordering organs, such as cervical carcinomas in women or prostatic carcinoma in men.
There are no screening tool to detect bladder cancer early. However, bladder cancer is detected by cystoscopy,
biopsy, IVP, CT Scan, renal ultrasound, and MRI (Osborn et al., 2014). Treatment of bladder cancer will depend on the
stage and grade of the cancer. According to Osborn, Wraa, Watson, and Holleran, if the cancer has not invaded the muscle,
the tumor can be removed by transurethral resection, intravesicular chemotherapy, in which the bladder is directly washed
with an antineoplastic, and intravesicular immunotherapy, in which the bladder is directly washed with Bacillus Calmette-
Guerin (BCG). Tumors that are too large to be removed transurethrally, are located away from the bladder neck and
urethral orifice, or have not responded to intravesical therapy, may be eligible for a partial cystectomy, although
recurrence is common. Tumors that have infiltrated the muscle require a radical cystectomy (removal of the entire bladder
and lymph nodes). In men, this may also include removal of the prostate, part of the urethra, and the seminal vesicles; in
women, the uterus, cervix, ovaries, fallopian tubes, and part of the vagina may be removed. Advanced bladder cancers
will also require radiation therapy and chemotherapy. These modalities may be used before or after cystectomy. Radiation
may be used as a primary treatment modality in patients who are not able to tolerate chemotherapy or have invading
cancer without lymph node involvement.
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?
Patients wife, daughter, and son help him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient states that he rarely gets upset. He also said, thats hard to say. I may go to study or do paperwork. However, most
times we work it out.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
Patient stated that he has no recent difficulties.
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 been hit punched or slapped? Patient stated that he had been hit before.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Patient stated that he has never been emotionally or physically harmed in other ways by a person in a close relationship
with him.
If yes, have you sought help for this? N/A
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
Erikson believes that ego integrity reflects a satisfaction with life and an understanding of ones place in the
life cycle, while, a sense of loss, discomfort with life and aging, and a fair of death are seen in despair (Treas
and Wilkinson, 2014). The task at this stage is the acceptance of ones life, worth, and eventual death. I believe
that this patient is satisfied with his life and accepts his place in the life cycle. He appears to have a healthy
relationship with his wife and children, and is in an acceptable physical state for his age and medical history.
The patient states that he rarely gets upset, and has never been emotionally or physically harmed by a person in
close relationship with him. Also, he stated that he is in a safe relationship with his wife and they have learnt,
over the years, how to compromise and make each other happy.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I do not believe that the Transurethral Resection of the Prostate procedure has a great impact on the patients
developmental stage. However, the patient mentioned that he is sexually active, and with this surgery, he may
not be able to participate into any sexually activities for a few weeks due to sexual dysfunction. This may
temporarily decrease his sense of satisfaction with life and he may feel as though he is not doing his job as a
husband.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient responded by saying, it just happened. I dont know what particularly caused it. I know my past lung and tongue
cancer must have been from smoking, but I dont know what caused the bladder cancer.
+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
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy?
When sexually active, patient do not take any precaution to prevent acquiring a sexually transmitted disease or an
unintended pregnancy.
Have any medical or surgical conditions changed your ability to have sexual activity?
Patient said that his current medical condition changed his ability to have sexual activity.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient has no concern about sexual health or how to prevent sexually transmitted disease or unintended pregnancy.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
The patients religious beliefs does influence his current condition. Because of his religious beliefs, he feels more confident in
recovering from his illness and surgery.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
The patient drinks Martini Volume: an ounce and a half (age 11 thru 82- currently)
Frequency: daily
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?
N/A How much? N/A For how many years? N/A
(age thru )
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?
The patient has never been exposed to any occupational or environmental Hazards/Risks.
5. For Veterans: Have you had any kind of service related exposure?
The patient has never had any kind of service related exposure.
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: Yes Diverticulitis Life threatening allergic reaction
Bathing routine: every morning Appendicitis Enlarged lymph nodes
Other: N/A Abdominal Abscess Other: N/A
Be sure to answer the highlighted area Last colonoscopy? N/A
HEENT Other: N/A Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: Not Known
Post-nasal drip Normal frequency of urination: 3x/day Other: N/A
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth: 1x/day
Diabetes Type:
(evenings)
Routine dentist visits: 4x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: N/A Osteoporosis
Other: N/A
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? N/A Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? N/A Encephalitis
last CXR? N/A menopause age? N/A Meningitis
Other: N/A Date of last Mammogram &Result: N/A Other: N/A
Date of DEXA Bone Density & Result:
N/A
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Frequency of prostate exam?
Hyperlipidemia Schizophrenia
Every 5 years
Chest pain / Angina Date of last prostate exam? 02/22/16 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other: N/A
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
General Constitution
Recent weight loss or gain
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health?
Patient believes that he is in pretty good shape for his age, especially because of his history of smoking.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
There is no problem that is not mentioned that the patient sought medical attention for with anyone.
Any other questions or comments that your patient would like you to know?
The patient said that he really likes to travel and he and his wife travel a lot.
General Survey: Height: 195 cm Weight: 105 kg BMI: 27.61 Pain: (include rating and
Patient has no obvious Pulse: 60 bpm Blood Pressure: (include location) location)
abnormalities Respirations: 17 br/min 141 mmHg SBP/56mmHg DBP No pain
Temperature: (route SpO2: 96% Is the patient on Room Air or O2?
taken?) 98.4 degrees- oral Room air
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: N/A Location: N/A Date inserted: N/A
Fluids infusing? no yes - what? N/A
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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: N/A
Comments: N/A
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
Calf pain bilaterally negative Pulses bilaterally equal: 3 [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 62 Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT:
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
GU Urine output: Clear Cloudy Color: Light pink Previous 24 hour output: 4300 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
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
Urinalysis February 23, 2016 RBC: 4.31 (L) Used to diagnose urinary
system and kidney
RBC Count disease. Red blood cells
Normal: 4.6-6.2 and hematuria are
expected abnormalities.
Cystoscopy February 22, 2016 The doctor examines the Main test used to
whole lining of the diagnose bladder cancer.
April 23, 15 bladder and urethra by
gently passing the
cystoscope through the
urethra and into the
bladder.
CT Scan NOT IN CHART Results may display renal Used to detect tissue
lesions and the abnormalities in the
progression of bladder kidney and urinary
cancer. system. Therefore this
should be done on a
patient with bladder
cancer. The results,
however, should be
abnormal.
Ultrasonography NOT IN CHART May detect metastasis Used to identify the size
outside of the bladder. of the kidneys and tissue
abnormalities. Therefore
this should be done on a
patient with bladder
cancer and the results
should be abnormal.
Excretory Urography NOT IN CHART Results may show Done to evaluate the
University of South Florida College of Nursing Revision September 2014 17
damage to the bladder structure, size, and
Normal: Normal and surrounding function of the kidneys,
structure, size, and structures by a tumor. ureter and bladder.
function of the kidneys, Therefore this should be
ureter and bladder. done on a patient with
bladder cancer. The
results, however, should
be abnormal.
3. Ineffective self-health management related to deficient knowledge as evidence by patient having unbalanced
nutrition regardless of his history of bladder cancer and hypertension.
4. Risk for acute pain related to reflex muscle spasm associated with Transurethral Resection of the Prostate.
5. Risk for urinary tract infection related to Transurethral Resection of the Prostate.
Perform focused physical A palpable kidney or bladder Kidney and bladder was not
assessment including, percussion provides direct evidence of dilated palpable. Hence, there was no
and palpation of the lower urinary collection system (Ackley obvious bladder distention or an
abdomen looking for obvious and Ladwig, 2014). enlarged kidney.
bladder distention or an enlarged
kidney.
Assist patient to adopt to normal Promotes sense of normality and Patient adopted to normal position
position when voiding. Instruct encourages passage of urine. when voiding. He stood and
them to stand and walk to the walked to the bathroom twice after
bathroom at frequent intervals after the catheter was removed.
catheter is removed.
Demonstrate behaviors to regain *Encourage fluid intake to 3000 Maintains adequate hydration and Patient drank moderate amount of
bladder/urinary control mL as tolerated. Limit fluids in the renal perfusion for urinary flow. fluid. Approximately 2300 mL.
evening, once catheter is removed. Reducing fluid intake at the right
schedule decreases the need to void
and interrupt sleep during the
night.
*Encourage patient to void when Voiding with urge prevents urinary Patient was able to void when urge
urge is noted but not more than retention. Limiting voids to every 4 was noted.
University of South Florida College of Nursing Revision September 2014 19
every 2 to 4 hours per protocol. hour (if tolerated) increases bladder
tone and aids in bladder retraining
(Ackley and Ladwig, 2014).
*Instruct patient to perform Helps regain control of the bladder, Patient was able to perform
perineal exercises: tightening sphincter, or urinary control and perineal exercises at different
buttocks, stopping and starting minimizes incontinence (Ackley intervals throughout the day.
urine stream. and Ladwig, 2014).
State absence of pain and Question the client regarding Pain management techniques can Patient mentioned having slight
tenderness during urination presence of pain in the area of the be implemented if needed. pain and tenderness during
bladder and possible aggravating urination.
and alleviating factors
Patient will:
Reduce hematuria as soon as Monitor the client closely for Clients at increased risk for Hematuria was noted. However, the
possible. hemorrhage/hematuria. bleeding may include older urine was pink, which suggests that
individuals over the age of 65 bleeding was controlled.
(Ackley and Ladwig, 2014). TURP
is a procedure that causes bleeding.
Bleeding should be monitored
closely.
Monitor all medications for the Antiplatelet medications can Aspirin was monitored carefully.
potential to increase bleeding, increase the risk of bleeding in
including aspirin. high-risk clients (Ackley and
Ladwig, 2014).
*Encourage patient to drink a lot of This will help to flush the bladder. Patients urine changed from a
fluid. darker pink to a lighter pink.
University of South Florida College of Nursing Revision September 2014 20
Avoid over distention of bladder *Encourage patient to void when Voiding with urge prevents urinary Patient voided when urge was
urge is noted. retention which may cause over noted.
distention of the bladder. Over
distention of the bladder can lead
to hemorrhage (Ackley and
Ladwig, 2014).
*Encourage the patient to decrease This will prevent urinary retention Patient had bathroom availability.
the intake of fluids when there is and bladder distention for long
no bathroom availability. periods of time.
Ambulate early to prevent Encourage patient to ambulate to Bleeding may cause thrombosis to Patient was able to ambulate to the
thrombosis and subsequent the bathroom, to the chair, and occur. Movements decreases the bathroom, to the chair, and around
embolism around the unit. risk of thrombosis and embolism. the unit.
Have the patient keep a record of This will give an idea of the The patient was able to walk
the number of times he ambulated activity level of the patient. around the unit about four times at
and the distance walked. different intervals within 4 hours.
He was also able to move around
his room.
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
Rehab/ HH
Palliative Care
Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for
practice (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.
Treas, L.S. & Wilkinson, J.M. (2014). Basic Nursing Concepts, Skills & Reasoning. Philadelphia: F.A. Davis
Company.
United States Department of Agriculture. (2016). SuperTracker: Food Tracker. Retrieved from
https://www.supertracker.usda.gov/foodtracker.aspx