UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Alexis Daubney

Assignment Date: 09/20/2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: B. J. S. Age: 47 Admission Date: 09/06/2016
Gender: Female Marital Status: Married Primary Medical Diagnosis: Right parietooccipital
tumor with metastatic adenocarcinoma
Primary Language: English
Level of Education: High School Diploma Other Medical Diagnoses: N/A
Occupation: Unemployed
Number/ages children/siblings: 8 siblings, 3 children (29, 28, 26), 2
grandchildren (5 and 2)
Served/Veteran: No Code Status: Full resuscitation
If yes: Ever deployed? Yes or No
Living Arrangements: mobile home, with husband Advanced Directives: Yes, living will
If no, do they want to fill them out?
Surgery Date: 09/09/2016
Procedure: Craniotomy
Culture/ Ethnicity /Nationality: White / Non-Hispanic
Religion: Catholic Type of Insurance: United Health

 1 CHIEF COMPLAINT:
“This cancer thing. It just spread. And now it is sort of everywhere.”

 3 HISTORY OF PRESENT ILLNESS:

47-year-old female presents to Florida Hospital Wesley Chapel the morning of 09/06/2016 due to changes in mental
status. She reports, “I have no clue how I got here”. Patient is transferred to Florida Hospital Tampa due to possible
subarachnoid hemorrhage. Patient was oriented to person, place, and time. Patient stated her pain was a 10 out of 10.
Patient is currently (09/20/2016) experiencing pain in her lower back. She reports the pain is, “dull, constant stabbing
pain”. Only Dilaudid and morphine are aiding in decreasing her pain level. The severity of her pain ranges from 6-10.
Throughout today’s assessment her pain level was reported to be a “6 or a 7”. Patient reports, “I started to forget the little
things” and “I started to have headaches”. Patient reports, “my pain is dull constant pain”.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Date Operation or Illness
Unknown Appendectomy
Unknown Tubal ligation
Unknown Osteoporosis
03/02/2016 Uterine cancer
08/18/2016 Hip total replacement anterior, reposition right upper femur intramedullary internal fixation device
09/09/2016 Craniotomy/tumor excision (right)
Current Chemotherapy, and radiation therapy
University of South Florida College of Nursing – Revision September 2014 1
 Patient was questioned regarding dates for operations and denies knowledge of dates for appendectomy, and tubal ligation
and onset date for osteoporosis.

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
FAMILY Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
Cause

Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes

Seizures
Arthritis
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 71 “old age”
Mother 81 “old age”
Brother 76
Brother --
Sister --
relationship

relationship

Comments:
Patient does not report knowledge of all siblings’ ages. Patient reports having 7 older brothers, and 1 older sister. Siblings with
reported medical history are included in the above chart. Patient’s mother had “breast cancer”. Patient’s brother had “esophageal
cancer”.

 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): patient reports 20 years ago
Adult Tetanus (Date): patient reports 5 years ago
Influenza (flu) (Date): patient reports last season
Pneumococcal (pneumonia) (Date): patient reports, “I am getting it this
year.”
Have you had any other vaccines given for international travel or
occupational purposes? Please List

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Patient states she has no allergies to medications, iodine, tape,
environmental allergens, etc.

Medications

Other (food, tape,

latex, dye, etc.)

University of South Florida College of Nursing – Revision September 2014 2

 5 PATHOPHYSIOLOGY:
Cancer targets a variety of organs and systems throughout the body. This specific patient was impacted by uterine cancer,
which metastasized to other systems including the bone and brain. Her primary medical diagnosis, “right parietooccipital
tumor with metastatic adenocarcinoma”, will be focused on with regards to pathology. Adenocarcinomas are
differentiated from carcinomas based on where they originate. Adenocarcinomas come from ductal or glandular structures
rather than the epithelial tissues. The disease is spread through glandular tissues to other areas of the body. Cancer can be
diagnosed through screening tests or through the investigation of symptoms. These diagnostics then lead to further
investigation by microscopy and analysis. Tumors are staged by the TNM system. This system differentiates between
tumor stages by observing the local tissues involved (T), node involvement (N), and the extent of metastasis (M). There
are multiple risk factors depending on the type of cancer including: age, family history, and environment. Cancer pain is
at the center of treatment goals. Pain can arise from “direct pressure, obstruction, invasion of a sensitive structure,
stretching of visceral surfaces, tissues destruction, infection, and inflammation” (Huether, & McCance, 2012). Cancers are
treated through chemotherapy, radiation therapy, and/or surgery. In this case, surgery was utilized to relieve the pressure
that the tumor caused on the brain. The prognosis varies depending on the type of cancer. According to the journal of
Current Oncology, “5-year survival rate for women with [uterine] cancer that has spread beyond the true pelvis to
adjacent organs is only 17%” (2015).

Reference: (Huether, & McCance, 2012).

 5 MEDICATIONS
Name docusate (Docusate sodium) Concentration Dosage Amount 100 mg

Route oral, capsule Frequency every 12 hours

Pharmaceutical class stool softeners Home Hospital or Both
Indication relieve constipation
Adverse/ Side effects common side effects include diarrhea, abdominal cramps, electrolyte disorders, rash
Nursing considerations/ Patient Teaching monitor possible electrolyte imbalances due to risk of diarrhea; auscultate abdomen for bowel sounds; monitor COCA (color,
odor, consistency, and amount) of bowel movements

Name famotidine (Pepcid) Concentration Dosage Amount 20 mg

Route INJ Frequency every 12 hours

Pharmaceutical class histamine-2 blocker Home Hospital or Both
Indication gastroesophageal reflux disease treatment
Adverse/ Side effects headache, dizziness, constipation, diarrhea, anaphylaxis, angioedema, Stevens-Johnson syndrome, AV block, arrhythmias
Nursing considerations/ Patient Teaching monitor for possible side effects; ensure patient knows side effects to look out for when taking this drug such as any rashes,
or heart palpitations

Name ferrous sulfate Concentration Dosage Amount 65 mg

Route Elixir, PO Frequency 2 times a day

Pharmaceutical class mineral, iron homeostasis Home Hospital or Both
Indication iron replacement
Adverse/ Side effects dyspepsia, nausea, vomiting, constipation, diarrhea
Nursing considerations/ Patient Teaching monitor iron parameters through lab work, and auscultate abdomen for bowel sounds

Name gabapentin (Neurontin) Concentration Dosage Amount 100 mg

Route oral, capsule Frequency 3 times a day, hold for sedation

Pharmaceutical class GABA receptor agonist Home Hospital or Both
Indication anticonvulsant
Adverse/ Side effects diarrhea, headache, dyspepsia, depression, dizziness, fatigue, anaphylaxis, angioedema, rhabdomyolysis
Nursing considerations/ Patient Teaching notify patient of side effects and the beginning signs of anaphylaxis at start of treatment; monitor behavioral changes and
mental status; monitor patients sedation level utilizing Richmond Agitation-Sedation Scale

University of South Florida College of Nursing – Revision September 2014 3

Name levetiracetam (Keppra) Concentration 400 mL/hr, infuse over 15 minutes Dosage Amount 1,000 mg

Route IV Frequency 2 times a day

Pharmaceutical class Antiepileptic Home Hospital or Both
Indication seizure prevention
Adverse/ Side effects headache, vomiting, fatigue, dizziness, irritability, vertigo, confusion
Nursing considerations/ Patient Teaching monitor creatinine at baseline, and behavioral changes; avoid abrupt withdrawal from medication

Name methylprednisolone (SoluMedrol) Concentration Dosage Amount 20 mg

Route REC Injection, IV Frequency every 12 hours

Pharmaceutical class corticosteroid Home Hospital or Both
Indication anti-inflammatory
Adverse/ Side effects hypokalemia, elevated BP, nausea and vomiting, impaired wound healing, increased risk of infection, with long term use Cushing syndrome,
anaphylaxis
Nursing considerations/ Patient Teaching monitor patient vital signs especially blood pressure and heart rate, due to long term usuage it may be necessary to check the
blood glucose level of the patient

Name metoprolol (Lopressor) Concentration Dosage Amount 25 mg

Route oral, tablet Frequency 2 times a day, NOW

Pharmaceutical class beta-blocker Home Hospital or Both
Indication decreased heart rate, force of heart contraction, workload of heart; lowered BP
Adverse/ Side effects dizziness, light-headedness, insomnia, weakness, dyspnea, mental depression, slow heart rate, chest pain, fainting, seizures,
Nursing considerations/ Patient Teaching monitor heart rate and blood pressure, monitor blood glucose, teach the patient techniques to take pulse and blood pressure,
avoid orthostatic hypotension, do not discontinue suddenly (due to risk of heart attack, and rebound hypertension)

Name morphine (MS Contin) Concentration Dosage Amount 45 mg

Route oral, tablet Frequency every 12 hours, hold for sedation and/or changes in VS
Pharmaceutical class opioid Home Hospital or Both
Indication pain relief
Adverse/ Side effects respiratory depression, hypotension, seizures, nausea/vomiting, dizziness, headache, flushing, urinary retention
Nursing considerations/ Patient Teaching monitor respiration rate, and pulse; ensure that pain scale of patient is monitored and recorded for prior to administration of
medication and 30 minutes after administration

Name simvastatin Concentration Dosage Amount 40 mg

Route oral, tablet Frequency at bedtime

Pharmaceutical class HMG-CoA reductase inhibitors Home Hospital or Both
Indication decrease LDL cholesterol level; increase HDL cholesterol level

Adverse/ Side effects GI discomfort, nausea, vomiting, constipation, flatulence, inhibit absorption of fat-soluble drugs and vitamins (A, D, E, K), increase action of
warfarin
Nursing considerations/ Patient Teaching assess for constipation by auscultating abdomen, take other drugs at least 1 hour before or 4-6 hours after, take with meals to
absorb intestinal cholesterol

Name hydromorphone (Dilaudid) Concentration Dosage Amount 2 mg

Route oral, tablet Frequency every 4 hours, PRN severe pain; hold for sedation and/or changes in VS
Pharmaceutical class opioid Home Hospital or Both
Indication pain relief
Adverse/ Side effects constipation, rash, dizziness, nausea, vomiting, respiratory depression, hypotension, seizures
Nursing considerations/ Patient Teaching ensure that pain scale of patient is monitored and recorded for prior to administration of medication and 30 minutes after
administration, monitor respiratory rate, ensure that patient moves slowly when changing position and utilizes the call light when ambulating

Name morphine Concentration Dosage Amount 2 mg

University of South Florida College of Nursing – Revision September 2014 4

Route INJ, IV Push Frequency every 3 hours, PRN moderate pain; hold for systolic BP less than 100
Pharmaceutical class opioid receptor agonist Home Hospital or Both
Indication pain relief
Adverse/ Side effects respiratory depression, apnea, seizures, dependency, nausea/vomiting, headache, edema, constipation
Nursing considerations/ Patient Teaching ensure that pain scale of patient is monitored and recorded for prior to administration of medication and 30 minutes after
administration, monitor respiration rate, and pulse; monitor bowel movements, and auscultate the abdomen

Reference: (Epocrates, 2014)

University of South Florida College of Nursing – Revision September 2014 5

 5 NUTRITION
Diet ordered in hospital? Soft food diet Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: Patient has knowledge of the MyPlate system. However,
Breakfast: coffee (2 cups) patient does not incorporate into each meal. Patient exceeds
the daily dietary limit for sodium intake, due to the
Lunch: sandwich (cold cut meat, with cheese, lettuce, and consumption of a variety of foods high in salt. The patient
tomatoes), iced tea, chips (Lays, or pretzels) does not consume enough calories to sustain her weight. It
will be important due to her condition to have her consume
Dinner: vegetable (canned or fresh), meat, starch (potatoes, foods high in nutritional value to sustain her weight. Since
rice) the patient may or may not continue with radiation and
chemotherapy it may be necessary to include specific foods
Snacks: pie, fruit to not increase her symptom of nausea. The patient should
be encouraged to implement her knowledge of the MyPlate
Liquids (include alcohol): soda (ginger ale), Gatorade, system into the rest of her meals to increase her caloric
juices (apple, grape) intake. It should also be recommended that she increase her
fresh fruit, fresh vegetable, and dairy consumption to better
balance her nutritional intake.

1 COPING ASSESSMENT/SUPPORT SYSTEM

Who helps you when you are ill?
“My husband.”

How do you generally cope with stress? or What do you do when you are upset?
“Sometimes I throw it off to the side. I hate doing that.”
“What happens when I am pissed at my husband, what do I do then?”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“Nothing, besides the cancer thing.”

University of South Florida College of Nursing – Revision September 2014 6

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? “A wicked long time ago.”

Have you ever been talked down to? “Yes, but not recently. That was 20 or so years ago.” Have you ever been hit
punched or slapped? “Yes, but not recently.”

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
“Not recently since high school.” If yes, have you sought help for this? “I got out of that relationship.”

Are you currently in a safe relationship? “Yes I am. I got me a hubby.”

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your
patient’s age group:
Intimacy vs. Isolation occurs at the approximate stage of “early adulthood (20-35 yr)”. Developmental task is “establishing intimate
bonds of love and friendship”. Successful competition of this stage is “ability to love deeply and commit oneself”. Unsuccessful
resolution of crisis leads to “emotional isolation: egocentricity”. (Varcarolis & Halter, 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is currently in the stage of intimacy vs. isolation. Though this stage does not correlate with the patient’s age range, she
presents with an assessment related to this developmental stage. The patient feels as if she is isolated from her family and friends due
to her condition. She stated that she felt “far from her husband” at times, due to her continual hospital stays. She stated, “What do I do
if I’m pissed at my husband? Then I am alone. He is the only person I have”. These statements directly relate to this stage of isolation.
She may have regressed from a later stage once she received her diagnosis earlier this year. Currently, she is not effectively navigating
through this stage of intimacy versus isolation. Support from family, friends, and small therapy groups may be necessary to help the
patient be successful in achieving intimacy with those around her.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The diagnosis of cancer impacts all aspects of life. The increase in hospitalizations leads to the patient not being able to interact in
their daily activities. The patient begins to feel a dependence on those around them, so there is a decrease in autonomy. This leads to
further isolation. This specific patient felt as if she was failing, by “not always being there anymore” stating “I can’t do everything I
used to do for everyone”.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
“Something I picked up from everything.”

What does your illness mean to you?

“Ding dong, hello?” knocks on bedside table, “time to look up.”

+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active? “Yes”
Do you prefer women, men or both genders? “Men”
Are you aware of ever having a sexually transmitted infection? “No”
Have you or a partner ever had an abnormal pap smear? “No”
Have you or your partner received the Gardasil (HPV) vaccination? “Yes, when I was 16 years old.”
Are you currently sexually active? “Not recently” If yes, are you in a monogamous relationship?
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
University of South Florida College of Nursing – Revision September 2014 7
pregnancy? N/A

How long have you been with your current partner? “Married for 17 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
What importance does religion or spirituality have in your life?
“I don’t know. Religion opens my eyes a little bit more. It makes me a bit wiser of a person. It gives me more perspective. It makes
me a better person.”
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
“It makes me a better person is all.”
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much? (specify daily amount) For how many years? 6 years
“Cigarettes” “2 packs a day” (age 16 thru 22 )

If applicable, when did the

Pack Years: 12 years
patient quit?
When the patient was 22 years
old.
Has the patient ever tried to quit? Yes. “I was sick of the
smell”
Does anyone in the patient’s household smoke tobacco? If
If yes, what did they use to try to quit? “I tried those
so, what, and how much? “No”
special cigarettes, but they didn’t work. I just weaned
myself off of them.”

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
How much? Patient reports “more
For how many years?
What? Patient reports “a little bit of than a few drinks”.
everything”. Patient did not answer follow up Volume: (age 15 thru 40s )
questions regarding specifics. Patient reports stopping drinking
Frequency:
“sometime in forties”.
If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
“Marijuana” How much? For how many years?
“About an ounce a day” (age 15 thru )
Patient states, “I quit a while ago, but
then with the cancer I started a little
bit. But I haven’t in a while.”
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No

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

5. For Veterans: Have you had any kind of service related exposure?
Not applicable

University of South Florida College of Nursing – Revision September 2014 9

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary Gastrointestinal Immunologic

Changes in appearance of skin Nausea, vomiting, or diarrhea Chills with severe shaking
Problems with nails Constipation Irritable Bowel Night sweats
Dandruff GERD Cholecystitis Fever
Psoriasis Indigestion Gastritis / Ulcers HIV or AIDS
Hives or rashes Hemorrhoids Blood in the stool Lupus
Skin infections Yellow jaundice Hepatitis Rheumatoid Arthritis
Use of sunscreen SPF: 50 Pancreatitis Sarcoidosis
Bathing routine: every day Colitis Tumor
Other: increased bruising Diverticulitis Life threatening allergic reaction
Appendicitis Enlarged lymph nodes
HEENT Abdominal Abscess Other:
Difficulty seeing Last colonoscopy? 15 years ago
Cataracts or Glaucoma Other: Hematologic/Oncologic
Difficulty hearing Anemia
Genitourinary
Ear infections nocturia Bleeds easily
Sinus pain or infections dysuria Bruises easily
Nose bleeds hematuria Cancer
Post-nasal drip polyuria Blood Transfusions
Oral/pharyngeal infection kidney stones Blood type if known: A positive
Dental problems Normal frequency of urination: 25 x/day Other:
Routine brushing of teeth 1/day Bladder or kidney infections
Routine dentist visits 0/year Metabolic/Endocrine
Vision screening 0/year Diabetes Type:
Other: experiences sinus pain with the
Hypothyroid /Hyperthyroid
change of seasons
Intolerance to hot or cold
Pulmonary Osteoporosis
Difficulty Breathing
Cough - dry Central Nervous System
Asthma CVA
Bronchitis WOMEN ONLY Dizziness
Emphysema Infection of the female genitalia Severe Headaches
Pneumonia Monthly self breast exam Migraines
Tuberculosis Frequency of pap/pelvic exam Seizures
Environmental allergies Date of last gyn exam? Ticks or Tremors
last CXR: 09/17/2016 at 1910 menstrual cycle irregular Encephalitis
menarche patient reports “When I was
Other: Meningitis
young, I don’t recall the year.”
Cardiovascular menopause 45 age
Hypertension Date of last Mammogram &Result: Mental Illness
Hyperlipidemia Date of DEXA Bone Density & Result: Depression
Chest pain / Angina Musculoskeletal Schizophrenia
Myocardial Infarction Injuries or Fractures Anxiety
CAD/PVD Weakness Bipolar
CHF Pain Other:
Murmur Gout
Thrombus Osteomyelitis Childhood Diseases
Rheumatic Fever Arthritis Measles
Myocarditis Other: Mumps
Arrhythmias Polio
Last EKG screening: 09/20/2016 at
Pain Scarlet Fever
1525
Other: Chicken Pox

University of South Florida College of Nursing – Revision September 2014 10

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
“None”

Any other questions or comments that your patient would like you to know?
“Nothing”

University of South Florida College of Nursing – Revision September 2014 11

±10 PHYSICAL EXAMINATION:

General Survey: patient Height 150 cm Weight 45.4 kg BMI 20.18 Pain: 6 out of 10 in
is a 47 year old female, Pulse 109 Blood Pressure: 123/69 in right “backside”, lower back,
with no visible signs of Respirations 18 brachial. coccyx area, and “right and
distress left knee”
Temperature: 97.7 orally SpO2 94 Is the patient on Room Air or O2

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
Patient mumbles often. There are sparse instances of clear and crisp dictation. Patient begins and moves on to multiple topics
with regards to specific questions in previous assessment.

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud

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
Central access device Type: Location: Date inserted:
Fluids infusing? no yes
Peripheral IV site Type: 22 gauge Location: Left AC Date inserted: 09/19/2016
no redness, edema, or discharge
Fluids infusing? no yes – 0.9% normal saline
Patient has head shaved from surgery; the hair is growing back evenly along scalp. There are staples present along the
incision from the craniotomy. There is no bruising or redness present around the staples. Removal of the staples is scheduled
for 9/20 or 9/21. Patient presents with bruising, prominent in right arm (due to previous IV, removed 09/13/2016).

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: teeth are uniform, clean, and without abnormalities
Comments: Patient reports excessive rheum, “I get lots of eye gunk.” Patient responds adequately to questions in appropriate
volume level.

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
University of South Florida College of Nursing – Revision September 2014 12
RML CL LLL CL
RLL CL
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent

Cardiovascular: No lifts, heaves, or thrills

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

PR Interval: 0.112 QRS Complex: 0.080 QT Interval: 0.288 Rate: 118 ST: 0.060 mV
The patient presents with a P wave, and is within normal limits for PR interval, and QRS complex. However, the patient
presents with a shortened QT interval, and presents with an increased rate. These measurements are consistent with sinus
tachycardia.
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: Radial: 3 Femoral: Popliteal: DP: 3 PT: 3
No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
Notes: Hands and feet slightly cool, patient was then given extra blanket; capillary refill equal bilaterally less than 3
seconds.

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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 09 / 19 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other – Describe:

GU Urine output: Clear Cloudy Color:Yellow Previous 24 hour output: 3117.08 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance to bedside commode
CVA punch without rebound tenderness

_____________________________________________________________________________________________________________
Musculoskeletal:  Full ROM intact in all extremities without crepitus
Strength bilaterally equal at 4 RUE 4 LUE 4 RLE 4 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
Notes: upper extremity and lower extremity strength 4/5 equal bilaterally; patient presented with strain when shifting
positions
University of South Florida College of Nursing – Revision September 2014 13
 Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative
Notes: Gait asymmetric, unbalanced, patient requires assistance; patient is oriented to self, place, and time; when patient is
asked questions regarding meal plan, family history, and overview of systems narrative there were instances that required
clarification, patient began to talk about items that were not presented in the line of questions.

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS

Diagnostic Exam Date Time Findings
MR brain WO 09/06 Metastatic cervical carcinoma and brain mass
contrast 1835 Large hemorrhagic metastatic lesions found in right occipital and
parietal lobes. Large vasogenic edema resulting in a trapped right
temporal horn. Lesion within left occipital bone with soft tissue
component deep into subdural space.
XR elbow 09/07 X-ray left elbow due to severe pain
0814 No fractures or lesions found upon XR.
MR brain W 09/07 Heterogeneously enhancing masses of right parietal-occipital junction
contrast 1114 resulting in vasogenic edema corresponding with metastases. Mass
effect in right hemisphere resulting in 6.5 mm of right to left subfalcine
herniation. Dural based enhancing soft tissue mass in left occipital.
MR brain WO 09/10 Interval right parietooccipital craniotomy, and resection of two solid
contrast 1011 parietal occipital lesions. No residual enhancing tumor.
CT head brain WO 09/16 Right parietal craniotomy for tumor resection with subdural hematoma
contrast 1121 unchanged in size. Extensive vasogenic edema resulting in 5.6 mm
midline shift.
XR chest 2V 09/17 X-ray chest due to chest pain
1910 Persistent left upper lobe mass, non-calcified progressive pulmonary
nodules
XR video/cine 09/19 Patient presented with dysphagia
swallow 0947 Found aspiration with thin liquids.
Results: patient receiving soft food diet.
NM bone scan 09/19 Scintigraphic osseous-metastatic disease greatest at right femur. This is
whole body 1448 consistent with patient’s increase in leg pain.
Lab Dates Trend Analysis
WBC White blood cell count The raise in WBC
9.0 09/06/2016 is consistent throughout throughout the hospital stay
10.8 09/13/2016 hospital stay. WBC is maybe due to the surgeries
10.8 09/20/2016 slightly higher than and procedures that the
Normal upon admittance. patient had while over her
4.8-10.8 hospital stay. It would be
necessary to continually
monitor the WBC count,
because if it exceeds the
normal range it may
indicate an infection.
University of South Florida College of Nursing – Revision September 2014 14
RBC Consistently low red This consistently low RBC
3.56 L 09/06/2016 blood cell count. led to the transfusion of
3.67 L 09/13/2016 non-autologus RBC into a
3.42 L 09/20/2016 peripheral vein on
Normal 09/08/2016. This was
4.20-5.40 necessary due to the
continually lowering RBC.
Hgb Consistently low This lab value reiterates the
9.4 L 09/06/2016 hemoglobin count. possibility of the patient
10.2 L 09/13/2016 being anemic, due to her
9.4 L 09/20/2016 progression of condition
Normal beginning to target the bone
12.0-16.0 marrow.

HCT Consistently low This lab value reiterates the

31.2 L 09/06/2016 hematocrit level. possibility of the patient
33.3 L 09/13/2016 being anemic, due to her
30.2 L 09/20/2016 progression of condition
Normal beginning to target the bone
36.0-48.0 marrow.

Platelet Platelet count is This lab value must be

359 09/06/2016 slightly lower than monitored due to her
224 09/13/2016 platelet level upon craniotomy, which requires
209 09/20/2016 admittance, however adequate platelet counts for
Normal well within normal recovery.
150-400 ranges.

RDW Red cell distribution This high value may is most

19.4 H 09/06/2016 width is consistently likely due to an iron
18.2 H 09/13/2016 high throughout stay. deficiency anemia. This is
18.3 H 09/20/2016 consistent with treatment
Normal and administration of
11.0-14.5 ferrous sulfate.

Neutrophils Absolute Neutrophils absolute This increase in absolute

6.18 H 09/06/2016 count is consistently neutrophils may be due to
8.59 H 09/20/2016 high throughout increase inflammation,
Normal hospital stay. infection, or stress. In the
0.90-4.50 case of this patient, this lab
value is most likely due to
inflammation regarding the
craniotomy. A contributing
factor may also be due to
stress from hospitalization.
Creatinine Creatinine levels were This lab value is necessary
0.5 L 09/06/2016 consistently low to monitor due to the
0.3 L 09/13/2016 throughout hospital medications that the patient
0.3 L 09/20/2016 stay. is currently taking. If the
Normal creatinine is higher than the
University of South Florida College of Nursing – Revision September 2014 15
 0.6-1.3 proper range it may indicate
dysfunction of the liver.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES

Diet: Soft Food Diet due to dysphagia and risk for aspiration 09/19/2016
Progression of diet from soft food diet to full food diet as tolerated.
Vitals:
 Vitals 0800
o Temp 97.7 HR 109 BP 123/69 RR 18 O2 94 via Rm Air
 Vitals 1200
o Temp 98 HR 100 BP 126/82 RR 18 O2 95 via Rm Air
 Vitals 1700
o Temp 97.8 HR 100 BP 126/82 RR 20 O2 94 via Rm Air
 Vitals 2000
o Temp 97.9 HR 107 BP 125/91 RR 20 O2 94 via Rm Air
 Note: Temperature was measured orally
Activity: patient is able to ambulate with assistance, patient utilizes a bedside commode, patient will meet with
physical therapy prior to discharge
Pain Management: patient will continue to be in contact with the pain management team; newly implemented
medication schedule will continue to be monitored for adequate suppression of pain after hospital stay; addressed
at follow up appointment
Radiation & Chemotherapy: patient may continue with radiation and chemotherapy upon follow up with
oncologist, and a plan may be set to complete another round of treatment

 8 NURSING DIAGNOSES
1. Chronic pain related to metastatic cancer as evidenced by pain score of 6 out of 10 and report of continual pain.
2. Activity intolerance related to weakness from cancer as evidenced by inability to ambulate without assistance,
verbal repot of weakness, and exertion discomfort.
3. Risk for aspiration related to dysphagia as evidenced by impaired swallowing.
4. Imbalanced nutrition less than body requirements related to metastatic adenocarcinoma as evidenced by nutritional
assessment, and decreased intake of food.
5. Risk for social isolation related to hospitalization as evidenced by spirituality assessment and coping assessment.

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

± 15 CARE PLAN
Nursing Diagnosis: Chronic pain related to metastatic cancer as evidenced by pain score of 6 out of 10, and verbal report of continual pain.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient uses a self-report pain tool Assess pain intensity level in client Single dimension pain ratings are Patient will report pain on a scale
to identify current pain level and using a valid and reliable self- valid and reliable as measures of of 0-10. Patient reported a pain of
establish a comfort-function goal report pain too, such as the 0-10 pain intensity levels “6 or 7” upon assessment.
by end of shift. numerical pain rating scale.
Ask the client to identify the pain This establishes a comfort-function Patient reported a goal pain level
level, on a self-report pain tool, goal to help manage pain at a level from 0-10, to progress comfort-
that will allow the client to perform that allows for improved function, function. This goal will be
desired activities and achieve an and decreased psychosocial reasonable and accessible.
acceptable quality of life. suffering.
Patient states the ability to obtain Assess pain level, sedation level, Tolerance to opioid induced Patient reports pain level that
sufficient amounts of rest and sleep and respiratory status at regular respiratory depression develops permits for adequate rest and sleep,
within 2 days of new pain intervals during opioid within days of regular daily opioid while not leading to heavy sedation
treatment regimen. administration in the inpatient dosing. Using a valid and reliable levels that are monitored by the
setting. sedation tool that identified distinct nursing staff.
changes in the client’s alertness
and arousability can provide
guidance for nursing action at each
level of sedation.
Emphasize to the client the Clients will find they are able to Patient reports the need to take a
importance of pacing activity and perform ADLs and achieve goals break before they experience
taking rest breaks before they are better when they are rested. discomfort due to an activity.
needed.
Patient can perform necessary or Encourage the client to plan Pain causes cognitive impairment. Patient reports the ability to
desired activities at a pain level activities around periods of greatest Clients will find it easier to complete some ADLs such as
less than or equal to the comfort- comfort whenever possible. perform ADLs, and social groups brushing teeth with limited
function goal within 4 days of new when they are rested and their pain pain/discomfort.
pain treatment regimen. is under control.
* Recognize that opioid therapy Initiation of opioid therapy with a Patient will adhere to pain
may be indicated for some clients short acting opioid administered management plan, and report a
experiencing chronic pain. around the clock followed by long decrease in pain to allow for the
acting opioid may be beneficial for completion of their comfort
more consistent pain control and function goal.
University of South Florida College of Nursing – Revision September 2014 17

Nursing Diagnosis: Activity intolerance related to weakness from cancer as evidenced by inability to ambulate without assistance, verbal repot of weakness,
Patient Goals/Outcomes
State at least two symptoms of
adverse effects of exercise and
report onset of symptoms
immediately, completed at the end
of shift.
Verbalize two reasons why they
need to gradually increase activity
based on testing, tolerance, and
symptoms, completed at the end of
shift.
Demonstrates increased tolerance
to activity, by ambulating to the
bathroom within 2 days.
University of South Florida College of Nursing – Revision September 2014
and exertion discomfort
Nursing Interventions to Achieve
Goal
Determine cause of activity
intolerance.
Instruct the client to stop activity
immediately and report to the
physician if the client is
experiencing the following
symptoms: new of worsened
intensity or increased frequency of
discomfort; tightness or pressure in
chest, back, neck, jaw, shoulders,
and/or arms; palpitations;
dizziness; weakness; unusual and
extreme fatigue; excessive air
hunger.
Help the client with energy
conservation and work
simplification techniques in ADLs.
Monitor and record the clients
ability to tolerate activity: note
pulse rate, blood pressure, monitor
pattern, dyspnea, use of accessory
muscles, and skin color before,
during and after the activity.
When appropriate, gradually
increase activity, allowing the
client to assist with positioning,
transferring, and self -care as
possible. Progress from sitting in
increased adherence to pain
management plan.
Rationale for Interventions
Provide References
Determining the cause can help
direct appropriate interventions.
These are common symptoms of
angina, and are caused by
insufficiency of coronary blood
supply. If symptoms last longer
than 5-10 minutes, a physician
should evaluate the client. Pulse
oximetry identifies hypoxia, and
pulse rate and arterial blood
oxygenation indicates exercise
tolerance.
Conserving energy through
techniques will enhance the
patient’s ability to complete ADLs
effectively.
These symptoms of intolerance to
activity and continuation of activity
may result in client harm.
This slow progression is due to the
need to evaluate for postural
hypotension, which can lead to
injury of the client.
Evaluation of Goal on Day Care
is Provided
Patient has identified actions that
are uncomfortable or intolerant.
This will better direct further action
to treat the intolerance.
Client will state two symptoms,
and report them upon increased
activity.
Patient will verbalize two
techniques of conserving energy,
such as clustering like activities
together.
Client is able to verbalize two signs
of intolerance and notify nursing
staff of intolerance, and rests.
The client will be able to progress
through some of the stages with
assistance, and will be able to
ambulate to the bathroom within a
2-day period.
18
 bed to dangling, to standing, to
ambulation.
* Refer to physical therapy for Collaborating with physical The client will be able to progress
strength training and possible therapy will help the patient gain in the amount of activities of daily
weight training, to regain strength, strength to potentially increase living she can complete.
increase endurance, and improve tolerance to activity over time.
balance.
Care Plan Reference: (Ackley, & Ladwig, 2014)

±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
 SS may be contacted to provide further options regarding care after hospitalization.
□Dietary Consult
 A nutritionist should be advised for the patient to ensure adequate nutritional intake.
□PT/ OT
 Physical therapy will be consulted to aid in the patient’s activities of daily living. The progression to increase activities can be addressed
through this collaboration.
□Pastoral Care
 Pastoral care will benefit the patient’s spiritual needs, and feelings of isolation from family and friends.
□Durable Medical Needs
□F/U appointments
 Follow up appointments with the oncologist are necessary to determine a path of care with continuing or not continuing with radiation and
chemotherapy.
 Follow up appointments will be made with physical therapy to continue to grow the patient’s strength to complete activities of daily living.
□Med Instruction/Prescription
 □ Are any of the patient’s medications available at a discount pharmacy? □Yes □ No
 There are multiple medications that will be continued.
o Morphine: oral tablet for long term pain management; Ferrous sulfate: anemia treatment; Hydromorphone: treatment of breakthrough
pain; Gabapentin: anticonvulsant prevention; Levetiracetam: prevention of seizures due to pathology of brain tumor
□Rehab/ HH
 Patient will not be sent home for discharge, but rather will be discharged to an assistive living facility. This is necessary to ensure that the
patient’s health is stable, and that she is able to complete some activities of daily living.
□Palliative Care
 Patient may benefit from further knowledge of palliative care and possible treatments or care options available.
University of South Florida College of Nursing – Revision September 2014 19
University of South Florida College of Nursing – Revision September 2014 20
 References

Epocrates. (2014). Epocrates Reference Tools for Healthcare Professionals (16.8) [Mobile application software]. Retrieved from

http://itunes.apple.com

Hirte, H., Kennedy, E. B., Elit, L., & Kee Fung, M. (2015, June). Systemic therapy for recurrent, persistent, or metastatic cervical cancer: A clinical

practice guideline. Current Oncology, 22(3), 211-219. Retrieved September 28, 2016, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462531/.

Huether, S. E., McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier Mosby.

SuperTracker: My Foods. My Fitness. My Health. Retrieved September 26, 2016, from https://www.supertracker.usda.gov/foodtracker.aspx#graph

Varcarolis, E. M., & Halter, M. J. (2014). Foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO:

Saunders/Elsevier.

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