UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Nicholas Travis

Assignment Date: 6/27/16
.
Agency: TGH
1 PATIENT INFORMATION
Patient Initials: J.H. Age: 56 Admission Date: 6/6/16
Gender: M Marital Status: Married Primary Medical Diagnosis Acute Myeloid
Leukemia
Primary Language: English
Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Tow Truck Driver Pancytopenia
Number/ages children/siblings: 3 daughters- ages 33, 30, 28

Served/Veteran: No Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: Lives at home with wife Advanced Directives: No
If no, do they want to fill them out?
Surgery Date: N/A Procedure:
Culture/ Ethnicity /Nationality: Native to US
Religion: Atheist Type of Insurance: Florida Blue

1 CHIEF COMPLAINT: For the past few months Ive been feeling really fatigued. Then earlier this
month got a rash on my stomach and felt very short of breath so I went to the hospital. Thats when they
told me I have leukemia.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient states that around March he started to notice that he was feeling tired all the time. He slowly began to weaker and
weaker. Over the course of 2 months the patient lost approximately 10 pounds and his appetite was noticeably worse. Pt
states that he also noticed that his arthritis pain in his left hand got noticeably worse during the month prior to his
admission. Then on 6/6/16 the pt had a sudden onset of severe fatigue, shortness of breath, and the appearance of an
abdominal rash. Pt states that he felt very faint and has never felt so bad in his life. The pt was brought to the hospital by
his wife and was soon after informed that he had AML. The pt was transferred to the oncology floor and began
chemotherapy. The pt complains of fatigue, which worsens after chemotherapy and improves after blood transfusions. Pt
is also complaining of sever left hand pain. Pt states that the pain occurs every day and is rated at an 8/10. The pain is a
constant aching pain that worsens with movement and improves with pain medication. The patient is currently continuing
his first round of chemotherapy and is expected to be discharged in early July.

University of South Florida College of Nursing Revision September 2014 1

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
2001 Arthritis
2009 Arthroplasty
1992 Hepatitis C
01/2011 Pneumonia
1980 Psoriasis
1988 Vasectomy
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,

applicable
)
Di
ed
Father MI X X X
at
60
Mother 78 N/A X X
Brother
Sister x5 N/A

relationship

relationship

Comments:
Patient states that he has 5 sisters, but is not certain of their ages (although he knows he has 3 older and 2 younger all close in age) or
medical problems. Pt has not been in contact with any of them for many years.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
University of South Florida College of Nursing Revision September 2014 2
 Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) Unknown
Adult Tetanus (Date) Is within 10 years? 2009 X
Influenza (flu) (Date) Is within 1 years? 12/8/15 X
Pneumococcal (pneumonia) (Date) Is within 5 years? Refused X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
NKA

Medications

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Acute Myeloid Leukemia or AML is a classification of hematologic cancer that arises in the myeloid cells (Huether & McCance,
2008). Inside the bone marrow are stem cells that develop into leukocytes, platelets and erythrocytes. Cells that do not develop into
lymphocytes are termed myeloid cells, which are the cells affected in AML. AML is labeled an acute disease due to the fat that it
affects the myeloid blasts, which are immature myeloid cells. These blast cells are rapidly dividing cells, which results in a rapidly
growing leukemia. Eventually the cancerous cells spill out of the bone marrow and into systemic circulation (What is acute, 2016).
According to Huether and McCance, The common pathologic feature of all forms of leukemia is an uncontrolled proliferation of
malignant leukocytes, causing an overcrowding of bone marrow and decreased production and function of normal hematopoietic cells
(2008).

There are several significant risk factors for AML. These risk factors include cigarette smoking, exposure to radiation, exposure to
benzene, hepatitis C, AIDS/HIV, and the HTLV-1 virus (Huether & McCance, 2008). In addition, exposure to certain dyes, nitrogen
mustard, pesticides/herbicides, and melphalan have all been linked to higher incidence of AML. Males over the age of 60 are the most
likely to develop the disease. It is believed that there is also a genetic aspect to AML and its incidence is higher in those with downs
syndrome, Bloom syndrome, Kostmann syndrome, and Wiskott-Aldrich syndrome (Randhawa, Khoury, &Ravandi-Kashani, 2016).

Diagnosis of AML is based off of patient presentation and procedural results. Patients will AML will often have a rapid onset of
symptoms due to the fact that the cancer affects the blast cells. Common sings and symptoms include fatigue, bleeding/bruising,
headache, AMS, fever, infections, and dyspnea. A biopsy will confirm the diagnosis if there is greater than 19% myeloid blasts in the
bone marrow (Randhawa, Khoury, &Ravandi-Kashani, 2016).

Treatment for Acute Myeloid Leukemia is centered around chemotherapy. For the majority of patients with AML chemotherapy is
initiated shortly after their diagnoses. The drug of choice for chemotherapy in these patients is cytarabine. Prognosis varies for patients
with AML. Factors like age, genetics, and physical health play a major role in survivability (Randhawa, Khoury, &Ravandi-Kashani,
2016).

University of South Florida College of Nursing Revision September 2014 3

 5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name- Concentration Dosage Amount
Dovonex (calcipotriene) 50mcg/g Thin layer
Route Frequency
Topically Twice daily
Pharmaceutical class
Both
Vit. D analog
Indication
Psoriasis
Adverse/ Side effects
Burning, skin irritation, dermatitis, rash, raised serum calcium level,
Nursing considerations/ Patient Teaching
Understand patients desire to use medication while in hospital. Need for skin care.

Name Concentration Dosage Amount

Tramadol (ultram) 50 mg/tab 50 mg
Route Frequency
PO Every 6 hrs PRN
Pharmaceutical class
Hospital
Opioid analgesic
Indication
Pain
Adverse/ Side effects
Flushing, constipation, nausea, vomiting, dizziness, headache, MI, hypoglycemia, seizure, dyspnea, respiratory depression
Nursing considerations/ Patient Teaching
Advise patient to watch for side effects. Let nursing staff know when pain medication is desired.

Name Concentration Dosage Amount

Neupogen (filgrastim) Unk 300 mcg
Route Frequency
SQ Every 6 hrs PRN
Pharmaceutical class
Hospital
Granulocyte colony-stimulating factor
Indication
Neutropenia
Adverse/ Side effects
Diarrhea, anemia, headache, anaphylaxis, spleen rupture, cough, fatigue, pain, rash, alopecia
Nursing considerations/ Patient Teaching
Patient learning. Patient likely has never heard of this medication and will not know what the benefit of administration will be.

Name Concentration Dosage Amount

Cytarabine (Depocyte) Unk 100mg
Route Frequency
IV Every 12 hrs for 7 days
Pharmaceutical class
Hospital
Antimetabolite
Indication
AML
Adverse/ Side effects
Anaphylaxis, neuropathy, sepsis, fever, diarrhea, rash, thrombophlebitis, ulcers of mouth/gi tract
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

Acetaminophen (Tylenol) 325mg/tab 325-650 mg
Route Frequency
PO Every 6 hrs as needed

University of South Florida College of Nursing Revision September 2014 4

Pharmaceutical class
Both
Centrally acting analgesic
Indication
Minor pain
Adverse/ Side effects
Nausea, constipation, liver failure, pnemonitis, agitation, headache, insomnia
Nursing considerations/ Patient Teaching

Name Concentration Dosage Amount

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

Micromedex.com

University of South Florida College of Nursing Revision September 2014 5

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Neutropenic Analysis of home diet- The patients home diet is not ideal.
Diet patient follows at home? Unrestricted His protein intake is high, which can be beneficial for the
24 HR average home diet: healing process. In addition, he is also exceeding his
Breakfast: 2 Eggs, Bacon, toast, and Orange Juice vegetable recommendation. However, the patient needs to
improve his fruit and dairy intake significantly. Perhaps
Lunch: Popeye chicken- Fried chicken, biscuit, mashed the most alarming is the patients sodium intake. The
potatoes, and a coke patient
has a daily intake of nearly 6,000 mg. This far exceeds the
Dinner: BBQ ribs, corn on the cob, and baked beans. 2,300 mg per day limit provided by my.plate. In addition,
the patient nearly quadrupled his recommended saturated
Snacks: Peanuts, apple, crackers fat limit (Supertracker). For this patient, it is recommended
that he
continue his intake of high protein and vegetables, while
Liquids (include alcohol): 1 soda a day, juice with avoiding fast food/fried foods. By cooking at home he can
breakfast, approximately 32 oz Per day of water. No significantly decrease his sodium intake. In addition, the
alcohol intake patient should consume foods that are high in antioxidants
as they have been studied extensively for their anti-cancer
properties.
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?- Patient states that being around his wife and dog makes him feel better.

How do you generally cope with stress? or What do you do when you are upset?- The patient states that when he is
stressed he likes to sit on the porch with his dog and smoke a cigarette.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)- Patient states
that it was initially an overwhelming and unexpected experience when he was first diagnosed. However he is currently
optimistic and looking forward to going home and seeing his dog.

+2 DOMESTIC VIOLENCE ASSESSMENT

University of South Florida College of Nursing Revision September 2014 6

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?________Yes______ Have you ever been hit punched or slapped?
__Yes____________

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_____________________No_____________________ If yes, have you sought help for this? ______________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons 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 X Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Basic Nursing defines generativity as the process of guiding the next generation, or improving the whole society. In
addition, it states that, stagnation occurs when development ceases: A stagnant middle adult cannot guide the next
generation or contribute to society (Treas & Wilkinson).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is in the generativity stage. He is in a unique situation, in that he is faced with a possibly fatal diagnosis. This
patient has spent much of his adult life raising his children. The patient states that his recent diagnosis has led to him
talking to each of his daughters multiple times a day.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The diagnosis of AML came as a complete shock to the patient. Initially, the patient most closely resembled the despair
stage. Although he did not meet the age requirement, what he faced upon diagnosis was similar to the struggles that the
elderly may encounter. However, as time passed the patient became optimistic about his situation and entered the stage of
generativity.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?- Smoking for so many years was probably the biggest thing.

What does your illness mean to you? It means I need to try to quit smoking and cherish the time that I have left.

+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
University of South Florida College of Nursing Revision September 2014 7
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? ___________Yes____________ If yes, are you in a monogamous relationship?
___________Yes______ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ____________Vasectomy__________

How long have you been with your current partner?_______________36 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

University of South Florida College of Nursing Revision September 2014 8

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
__
None, the patient is not a spiritual person and has no religious affiliations.
____________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____________No__________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes-X No
If so, what? Cigarettes How much?(specify daily amount) For how many years? 35 years
2 packs/day (age 21 thru 56 )

If applicable, when did the

Pack Years: 70
patient quit?- Upon admission

Does anyone in the patients household smoke tobacco? If Has the patient ever tried to quit?- Multiple times
so, what, and how much?- No If yes, what did they use to try to quit?- Nicotine gum

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes X No
What? Beer, vodka How much? -5 Beers For how many years?
Volume: (age 21 thru 30 )
Frequency: 5 times a week
If applicable, when did the patient quit?
At age 30

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes NoX
If so, what?
N/A How much? For how many years?
N/A (age thru )

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks- Patient states that his
only exposures he was aware of was to gasoline/diesel and truck exhaust.

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

University of South Florida College of Nursing Revision September 2014 9

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health?- Obviously I have been better. However, prior to this incident I generally considered my self
as average. I know I smoked and my diet could be better, but up until now I havent had any major issues. I guess I was pretty lucky.

Integumentary: The patients skin is intact throughout. The rash on the patients skin has subsided. The rash was
determined to be leukemia cutis. Patient states that when he first saw the rash it looked a lot like the psoriasis
that he has had in the past, but he normally didnt get it on his abdomen. The patient has some minor bruising
from prior IV access prior to PIC line insertion. Pt has no signs of skin breakdown. Pt states that he typically did
not use sunscreen in the past and he showers daily.
HEENT:- Patient states that his vision has gotten worse in recent years. Patient uses reading glasses for close
objects. Patient does not use glasses or contacts for daily use. Patient states that he has no hearing loss/tinnitus
and he does not use hearing aids. Pt states that he has no painful or difficulty swallowing. Pt has some signs of
hair thinning/loss.
Pulmonary: Patient denies any current DIB, cough, chest tightness, or other respiratory complaints. Patient states
that he has no history of respiratory conditions other than an episode of pneumonia. Patients lung sounds are
clear bilaterally with adequate tidal volume.
Cardiovascular: Patient denies any history of cardiovascular conditions. Patient denies any chest
pain/discomfort, nausea, abdominal pain, neck/jaw pain, or headache. Patients father does have a cardiovascular
history.
GI: Patient states that he has no history of GI issues. Patient denies any abdominal pain, nausea/vomiting,
diarrhea, dark/bloody stools, constipation, or other complaints. Pt states that he had a normal bowel movement
this morning.
GU: Patient has no catheter. Patient denies any painful or difficulty urinating.
Women/Men Only: Patient denies any ED, prostate issues, or sexual dysfunction.
Musculoskeletal: Pt states that he has a history of arthritis and is currently having severe pain in his left hand.
Patient denies any other musculoskeletal pain.

University of South Florida College of Nursing Revision September 2014 10

Immunologic: Patient has a diagnosis of AML. Patient denies any history of frequent infections/illnesses.
Hematologic/Oncologic: Patient is currently diagnosed with AML. Patient has no history of other cancers.
Metabolic/Endocrine: Patient denies any history of endocrine disorders. Patient states that his mother had Type
II diabetes.
Central Nervous System: Patient denies any history of stroke, TIA, or neurological disorders. Patient denies any
tremors, numbness, tingling, difficulty ambulating, or similar symptoms.
Mental Illness: Patient denies any history of mental illness. Patient denies any depression, anger, bipolar
disorder, or any history of mental illness in his family.
Childhood Diseases: Patient denies any history of childhood diseases.

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? Patient denies any questions at this point in
time, but states he will let the staff know if he has any.

10 PHYSICAL EXAMINATION:
General survey ___56 y/o male of average height and weight, in no apparent distress________________________
Height ___59______Weight___155___ BMI ___22.9_____ Pain (include rating and location_8/10 L hand______
Pulse__71__ Blood Pressure (include location)___124/56 L upper arm____Temperature (route taken)____98.8
oral________
Respirations__14_____ SpO2 __________100%___ Room Air or O2_______RA_________
Overall Appearance____Patient appears to be a well-groomed and clean middle-aged male. Patient responds
appropriately and maintains eye contact. Patient is able to ambulate without significant difficulty.________
Overall Behavior Patent is awake and calm throughout assessment. Pt appears to be relaxed and at ease. Patient
does not appear to be visibly upset or in pain. ___________
University of South Florida College of Nursing Revision September 2014 11
Speech__Patients speech is appropriate for his age and is clear.________________________________________
Mood and Affect_Patient is pleasant and cooperative with the assessment._____________________
Integumentary____Skin is warm, pink, and dry. No rashes noted. Patient denies any skin complaints.
_______________
IV Access___________PIC Line left Arm____________________________
HEENT___Patients face is symmetrical, hair is evenly distributed, sclera is white, conjunctiva is clear, PERRLA,
dentition intact, no nystagmus noted_______________________
Pulmonary/Thorax_Lung sounds clear in all fields. Good chest rise and fall. Resonant upon percussion.
Cardiovascular___S1 and S2 present, no adventitious heart sounds noted. Regular rate and rhythm. Pulses rated at
a 2+ bilaterally. Capillary refill of less than 2 seconds. ______
GI___Patients abdomen is soft and non tender. + normoactive bowel sounds. Patient states that he had a normal
bowel movement this morning. Tympany noted on percussion ____________
GU__________Patient denies any painful or difficulty urinating. Patient states that his urine is yellow/clear.
______________
Musculoskeletal____Patient states that he is having arthritis pain in his left hand. Patient ambulates without
difficulty. Patient has good ROM in all extremities rated at a 5+.___________________________
Neurological- Patient is A+OX4 with a GCS of 15. Patient has a steady gait and no facial droop, arm drift, or other
signs of neuro defects.

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

WBC Patients WBC count had Low WBC count opens
0.53 L (06/27/2016) been trending downward the pt up to infection.
due to chemotherapy Unfortunately, with the
AML many of his WBCs
are already not
functioning.
RBC Patients RBC count The low RBC count will
varies. It drops with result in anemia.
2.21 L (06/27/2016) chemotherapy and rises Oxygen delivery will be
with blood transfusions. effected and patient may
feel short of breath,
especially with exercise
Hemoglobin Patients hemoglobin Hemoglobin is
(06/27/2016) varies. It drops with important for oxygen
6.8 L chemotherapy and rises transport in the blood.
with blood transfusions. See above
Hematocrit Patients hematocrit With the low RBC count
(06/27/2016) varies. It drops with this result is to be
19.7 L chemotherapy and rises expected.
with blood transfusions.
Sodium Patients sodium levels Sodium is below normal
(06/28/2016) have been slightly low, limits. Patients appetite
University of South Florida College of Nursing Revision September 2014 12
 130 L but steady. is low and he has been
receiving some
hypertonic medications.
Potassium Patients levels drop Patients appetite is low
3.6 (06/28/2016) below normal often, at and he is malnourished.
which point, IV
potassium is
administered.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is currently undergoing chemotherapy. As a result of the chemo he has frequent blood transfusions.
Vitals are recorded q4h and the patient ambulates often with no need for physical therapy. Patient is
currently being stabilized after initial chemotherapy treatment and is working towards discharge.

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

1. Ineffective protection related to AML as evidence by abnormal blood profiles, neutropenia, and universal precautions.

2.Risk for bleeding related to AML as evidence by bruising, l eukemia cutis, and decreased platelet count.

3. Risk for prone health behavior related to smoking as evidence by smoking history and related health problems.

4.

University of South Florida College of Nursing Revision September 2014 13

5.

University of South Florida College of Nursing Revision September 2014 14

 15 CARE PLAN
Nursing Diagnosis: 1. Ineffective protection related to AML as evidence by abnormal blood profiles, neutropenia, and universal precautions.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
The patient will be able to identify Place patient in a private room. A private room can help prevent The patient did not report any signs
ways to prevent infection within 24 exposure to pathogens from other or symptoms of infection.
hrs of hospital say. patients and their families (Ackley
& Ladwig, 2011, p. 675).
Patient is in a private room.

Enforce hand washing for staff and Hand washing and avoidance of
visitors. pathogen exposure can help Patients wife follows hand
prevent infection (Ackley & washing and universal precautions
Ladwig, 2011, p. 674). while visiting.

Implement general precautions Having others and the patient wear Patient uses a mask when
(PPE) to help protect patient from a mask helps to prevent infection ambulating outside of his room.
pathogens. (Ackley & Ladwig, 2011, p. 674).

Inform Patient to Monitor and Progression of infection may be

report all signs of infection (fever, very rapid so the recognition needs
chills, pain, etc) to be fast as well (Ackley &
Ladwig, 2011, p. 674).

The patient will be able to identify Check the patient often for signs of Bleeding can present as melena, Patient cooperates well with
the signs of bleeding within 24 hrs bleeding. petechiae, hematuria, epistaxis, or assessments and readily discloses
of hospital stay. hematemesis (Ackley & Ladwig, any new findings.
2011, p. 675).

Monitor patients blood work often. Clotting studies and platelet counts Blood work is preformed often and
University of South Florida College of Nursing Revision September 2014 15
 can evaluate a patients risk for blood products are administered
bleeding (Ackley & Ladwig, 2011, PRN.
p. 675).

Give medications via PICC line or SQ and IM injections can increase Subcutaneous injections are
PO only. bleeding in this patient (Ackley & preformed with this patient, but IM
Ladwig, 2011, p. 676). injections are avoided.

The patient will remain infection Patient will practice good hand Hand washing and avoidance of Unable to evaluate because this is a
free upon discharge until his next washing at home. pathogen exposure can help long-term goal.
scheduled admission for prevent infection (Ackley &
chemotherapy. Ladwig, 2011, p. 674).

Patients will provide excellent oral Patients on chemotherapy are at

care while at home. risks for complications of
stomatitis (Ackley & Ladwig,
2011, p. 674).

Patient will remain active upon An adequate activity level can help
discharge, patient well being (Ackley &
Ladwig, 2011, p. 675).

University of South Florida College of Nursing Revision September 2014 16

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

Patient will return in future for additional chemotherapy.

University of South Florida College of Nursing Revision September 2014 17

 References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Huether, S. E., & McCance, K. L. (2008). Understanding

pathophysiology (5th ed.). St. Louis, MO: Mosby/Elsevier.

Micromedex Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Micromedex.

Randhawa J.K., Khoury J, Ravandi-Kashani F (2016). Adult Acute Myeloid Leukemia. In Kantarjian H.M.,

Wolff R.A. (Eds), The MD Anderson Manual of Medical Oncology, 3e.

http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?

bookid=1772&Sectionid=121896430.

SuperTracker: My Foods. My Fitness. My Health. (n.d.).

https://supertracker.usda.gov/

Treas, L. S., & Wilkinson J. M. (2014). Basic nursing:

concept skills and reasoning F.A. Davis

What is acute myeloid leukemia? (2016, February 22). http://www.cancer.org/cancer/leukemia-

acutemyeloidaml/detailedguide/leukemia-acute-myeloid-myelogenous-what-is-aml

University of South Florida College of Nursing Revision September 2014 18