UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Dominga Needham
Assignment Date: 3/3/17
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Tampa General Hospital
 1 PATIENT INFORMATION
Patient Initials: C.R. Age: 32 Admission Date: 2/16/17
Gender: M Marital Status: Single Primary Medical Diagnosis
Primary Language: English Abdominal pain
Level of Education: High School Graduate/EMS School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): EMS/Firefighter N/A
Number/ages children/siblings:
Siblings: 1 brother, age 31
Served/Veteran: No Code Status: Full
If yes: Ever deployed? Yes or No
Living Arrangements: Advanced Directives:
If no, do they want to fill them out?
Patient lives in a one story house with his mother. Surgery Date: 2/16/17 Procedure: ERCP
Culture/ Ethnicity /Nationality: Caucasian
Religion: Christian Type of Insurance: N/A

 1 CHIEF COMPLAINT:
Patient presented to Tampa General Hospital for a scheduled endoscopic retrograde cholangiopancreatography (ERCP)
procedure, and was admitted after the procedure due to complaints of “severe abdominal pain from pancreatitis.”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 32 year old male with PMH of chronic pancreatitis (secondary to alcohol abuse) complicated by pancreatic
pseudocyst, cystogastrostomy, PD duct disruption, and opioid dependence presenting from GI interventional services after
an ERCP for observation. Patient presents with persistent abdominal pain and underwent a repeat ERCP for evaluation of
PD stent. Patient reports significant periumbilical abdominal pain that radiates to his back, which has been persistent since
his procedure. Patient describes the duration as constant, and characteristics of the pain as a “stabbing sensation.” Patient
is aggravated by touch and movement, and feels medication is the only relief for his pain. Patient rates pain at a 9/10, and
states it decreases to a manageable 5/10 with pain medication. Patient reports that he is typically able to tolerate pain at
home as long as he has pain medications. Patient denies recent alcohol use (states last drink was 8 months ago). Patient
states having difficulty paying for pain and nausea medications and would like SW assistance with medications. Patient
has not set up an appointment with a pain management doctor despite ongoing recommendations by inpatient medical
team for the past 3 months.

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

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 9/26/16 ERCP - No complications noted.
9/26/16 Gastrostomy – scheduled before ERCP. No complications noted.
11/29/16 ERCP - No complications noted.
1/10/17 MRCP – scheduled with ERCP. No complications noted.
1/10/17 Age (in years) ERCP - No complications noted.

2

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
)
de
ce
Father unknown
as
ed
Mother 57
Brother 31
Sister
relationship

relationship

relationship

Comments: Patient states father was “drinking for as long as I can remember, he never tried to quit” (cause of death of father is
unknown, patient refused conversation on this topic). States mother’s environmental allergies include pollen. Other than this, patient
denies any other family health issues.

 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 (5/2014) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

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 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
Ambien Patient experiences adverse effect of becoming extremely hyperactive.
Morphine Patient experiences itching.
Medications

N/A 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)
“The pathophysiology of acute pancreatitis is characterized by a loss of intracellular and extracellular compartmentation,
by an obstruction of pancreatic secretory transport and by an activation of pancreatic enzymes. In biliary acute
pancreatitis, outflow obstruction with pancreatic duct hypertension and a toxic effect of bile salts contribute to disruption
of pancreatic ductules, with subsequent loss of extracellular compartmentation. Alcohol induces functional alterations of
plasma membranes and alters the balance between proteolytic enzymes and protease inhibitors, thus triggering enzyme
activation, autodigestion and cell destruction. Once the disease has been initiated, the appearance of interstitial edema and
inflammatory infiltration are the basic features of acute pancreatitis. The accumulation of polymorphonuclear
granulocytes in pancreatic and extrapancreatic tissue, and the release of leukocyte enzymes play an essential role in the
further progression of the disease and in the development of systemic complications. Activation of different cascade
systems by proteolytic activity, and consumption of alpha 2-macroglobulin further characterize the severe clinical course
of acute pancreatitis” (Adler & Glasbrenner, 1993).

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name acetaminophen (Tylenol) Concentration 2 tablets (325 mg each) Dosage Amount 650 mg

Route oral Frequency every 6 hours PRN

Pharmaceutical class analgesic Home Hospital or Both
Indication use for mild pain (1-3/10)
Adverse/ Side effects unusual bleeding or bruising, coffee-ground emesis
Nursing considerations/ Patient Teaching be cautious when taking medication with kidney or liver disease

Name docusate sodium (Colace) Concentration 1 capsule Dosage Amount 100 mg

Route oral Frequency BID

Pharmaceutical class stool softener Home Hospital or Both
Indication constipation
Adverse/ Side effects diarrhea, stomach pain, cramping, rectal bleeding
Nursing considerations/ Patient Teaching do not take if experiencing diarrhea, do not take with drugs containing phenolphthalein

Name enalaprilat (Vasotec) Concentration 0.5 mL Dosage Amount 0.625 mg

Route intravenous Frequency PRN

Pharmaceutical class ACE inhibitor Home Hospital or Both
Indication hypertension

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Adverse/ Side effects dry cough, dizziness, lightheadedness, or weakness
Nursing considerations/ Patient Teaching take medication if SBP > 170 or DBP > 100.

Name enoxaparin (Lovenox) Concentration 40mg/1mL injection Dosage Amount 40 mg

Route subcutaneous Frequency daily

Pharmaceutical class anticoagulant Home Hospital or Both
Indication prevent blood clots
Adverse/ Side effects bleeding, shortness of breath, headache
Nursing considerations/ Patient Teaching medication thins blood, making bleeds harder to stop – take necessary precautions

Name hydromorphine (Dilaudid) Concentration 1 tablet Dosage Amount 2 mg

Route oral Frequency every 4 hours PRN

Pharmaceutical class narcotic Home Hospital or Both
Indication severe pain (7-10/10)
Adverse/ Side effects extreme dizziness, lightheadedness, confusion
Nursing considerations/ Patient Teaching medication can cause respiratory distress and death if combined with alcohol, use for pain not controlled by oxycodone
or Toradol

Name ketorolac (Toradol) Concentration 15mg/1mL injection Dosage Amount 15 mg

Route intravenous Frequency every 6 hours PRN

Pharmaceutical class nonsteroidal anti-inflammatory drug Home Hospital or Both
Indication moderate pain (4-6/10)
Adverse/ Side effects headache, tinnitus, vision changes
Nursing considerations/ Patient Teaching do not administer medication for greater than five consecutive days, medication may cause intestinal bleeding

Name Lactated Ringer’s infusion Concentration 1000 mL bag Dosage Amount 120mL/hr

Route intravenous Frequency continuous

Pharmaceutical class Home Hospital or Both
Indication fluid electrolyte replacement
Adverse/ Side effects fluid overload, pulmonary edema
Nursing considerations/ Patient Teaching observe patient for fluid retention

Name lipase-protease-amylase (Creon 24) Concentration 3 capsules Dosage Amount 24,000, 76,000, 12,000 per
capsule
Route oral Frequency TID
Pharmaceutical class Home Hospital or Both
Indication contains digestive enzymes to break down food in patients with pancreatitis
Adverse/ Side effects dizziness, headache, abdominal pain/cramps
Nursing considerations/ Patient Teaching medication can affect blood sugar levels. Do not drink alcohol while on this medication

Name ondasteron (Zofran) Concentration 1 tablet Dosage Amount 4 mg

Route oral Frequency every 6 hours PRN

Pharmaceutical class 5-ht3 antagonist Home Hospital or Both
Indication prevents nausea and vomiting
Adverse/ Side effects headache, tiredness/weakness, constipation or diarrhea
Nursing considerations/ Patient Teaching medication can have a dizzying effect – take caution operating heavy machinery

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Name oxycodone (Roxicodone) Concentration 1 tablet Dosage Amount 5 mg

Route oral Frequency every 4 hours PRN

Pharmaceutical class narcotic Home Hospital or Both
Indication treats severe pain (7-10/10)
Adverse/ Side effects extreme dizziness, lightheadedness, confusion
Nursing considerations/ Patient Teaching High risk of overdose, which can cause death. Do not stop medication suddenly. Medication may cause constipation –
take with laxative to prevent/treat constipation.

Name senna (Senokot0 Concentration 1 tablet Dosage Amount 100 mg

Route oral Frequency BID

Pharmaceutical stool softener Home Hospital or Both
Indication Relieves constipation.
Adverse/ Side effects stomach/abdominal pain/cramping, nausea, diarrhea, weakness
Nursing considerations/ Patient Teaching take medication with full glass of water. Medication may turn urine reddish-brown (this is normal)

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Clear liquid Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
24 HR average home diet: Patient states that at-home diet is poor because “my
stomach is usually in too much pain to eat, and all I can
handle is Boost and Jello.” When patient’s pain levels are
manageable (5/10 per patient), patient is able to manage
more supplemental food. However, patient’s diet still does
not meet the daily-recommended calorie intake. Patient’s
status for the daily food group targets is “under” in all
categories. On average, patient consumes 108g of sugar per
day, while MyPlate recommends only 50.
Recommendations for this patient centers around managing
pain in order to be able to tolerate food, as well as finding
other sources of nutrition such as other supplemental
energy drinks for when pain restricts patient from eating.
Breakfast: 1 Boost, 1 scrambled egg

Lunch: 1 Boost, 1 grilled cheese sandwich

Dinner: 1 Boost, 1 grilled chicken salad

Snacks: 1 Boost, 1 cup Jello

Liquids (include alcohol): Water

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 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, “my mother comforts me and helps me when I’m sick.”
How do you generally cope with stress? or What do you do when you are upset?
Patient states that he enjoys activities such as shooting and fishing to de-stress.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states recent feelings of social anxiety, which is a new onset.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”

Have you ever felt unsafe in a close relationship? _No____________________________________________

Have you ever been talked down to? No___ Have you ever been hit punched or slapped? ___No____

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

Are you currently in a safe relationship? N/A (No relationship)

 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:
 “ Occuring in young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward 
longer­term commitments with someone other than a family member. Successful completion of this stage can result in  happy 
relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and 
relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love” 
(McLeod, 2013).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
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My patient is in the “intimacy vs. isolation” aspect of this stage. In this stage, individuals are expected to begin expanding
relationships further than family and friends and developing more intimate relationships. This patient recently got out of a
long-term long distance relationship, however he feels confident that he is in the healing process and states he is ready to
“get back out there and try again.” For this reason, the patient falls in the “intimacy” category because he is not allowing
his medical circumstances to hold him back from proceeding on with his developmental stages. “Success in this stage
leads to the virtue of love” (McLeod, 2013) and this patient is actively seeking this in relationships further than family.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
The hospital stay and diagnosis of pancreatitis does not limit the patient in his developmental stage. Patient is determined
to not let his disease have an impact on his current and future relationships.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
Patient believes that his lifestyle choices contributed to the cause of his illness. He states, “if I didn’t drink so much when
I was younger, I probably wouldn’t be having all of these problems.”

What does your illness mean to you?

Patient states, “my illness means that I made poor choices in the past and this is the consequence of that.”

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”

Have you ever been sexually active?_Yes____________________________________________________

Do you prefer women, men or both genders? _______Women_____________________________________
Are you aware of ever having a sexually transmitted infection? ___No________________________________
Have you or a partner ever had an abnormal pap smear?_No__________________________________________ Have
you or your partner received the Gardasil (HPV) vaccination? __No_____________________________

Are you currently sexually active? __No_____________ If yes, are you in a monogamous relationship?
__N/A_________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or
an unintended pregnancy? __Condoms and birth control____________

How long have you been with your current partner?_Patient recently got out of a 9 month relationship with his previous
partner.____________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? __No_________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient states that religion plays a small role in his life, and doesn’t have much significance in his daily living.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Patient states that his religious beliefs have no influence to his current condition.
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 20 years
Chewing tobacco ½ can per day (age 13 thru current )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? No
so, what, and how much? If yes, what did they use to try to quit?
Mother smokes approximately one pack per day of cigarettes.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
How much? Patient states “around 8-
What? For how many years? 16
9 drinks every night”
Johnny Walker Volume: 1.5 oz per drink (age 15 thru 31 )
Frequency: Daily
If applicable, when did the patient quit?
Patient quit drinking 1.5 years ago after complications with pancreas became too severe for him to continue comfortably
drinking.

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? 6
Patient states, “not very often,
just a little bit with friends (age 16 thru 22 )
every few months.”

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
2006

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient states he was exposed to radiation during the time that he worked in a nuclear power plant.

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

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 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 30 Diverticulitis Life threatening allergic reaction
Bathing routine: daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy? 2016
HEENT Other: 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: unknown
Normal frequency of urination:
Post-nasal drip Other:
6x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth
Diabetes Type:
3x/day
Routine dentist visits
Hypothyroid /Hyperthyroid
2x/year
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? 2017 menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps

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 Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2/2017 Arthritis Chicken Pox
Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Patient states, “other than my pancreas, I have no other health issues.”

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
N/A

Any other questions or comments that your patient would like you to know?
N/A

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±10 PHYSICAL EXAMINATION:

General Survey: patient Height 182.9cm Weight 92.6kg/204lb BMI 27.7 Pain: (include rating and
was pleasant and Pulse 85 Blood Pressure: (include location) location)
talkative. Respirations 17 132/85 9/10 in the
Temperature: (route SpO2 Is the patient on Room Air or O2 abdomen/radiating towards
taken?) 98.1 orally 95% the back.
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

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

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

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

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: 20 gauge peripheral IV, intact Location: Left arm Date inserted: 2/16/17
Fluids infusing? no yes - what? Lactated ringers

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 / 3mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth were straight and white.
Comments:

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML CL LLL CL
RLL CL

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

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

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:3 Carotid: 3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 3 DP: 3 PT: 3
No temporal or carotid bruits Edema: 0 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

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

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 2 / 17 /2017 ) 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: patient described emesis as “yellowish and chunky.”
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other – Describe: Soft, exquisitely tender in epigastric and periumbilical region, non-distended. Percussion of abdomen
was not completed due to acute abdominal pain patient was experiencing.

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 1500 mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal:  Full ROM intact in all extremities without crepitus

Strength bilaterally equal at _5__ RUE __5__ LUE _5__ RLE & _5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: positive negative

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as

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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

Serum Lipase 2/4/17 Elevated (171) Elevated due to acute
pancreatitis.
Serum Amylase 2/4/17 Elevated (139) Elevated due to
pancreatitis.
Total Bilirubin 2/4/17-2/17/17 Increasing (0.5-0.9) Elevated levels may
indicate common bile
duct are blocked.
White Blood Cells 2/4/17 Within normal range Elevated WBC count may
(10.11) indicate a pancreatic
attack.
CT scan with contrast 2/4/17 Initial CT scan, no trend CT scan revealed no
established unknown abnormalities.
ERCP 2/16/17 Scheduled ERCP, no ERCP revealed damaged
trend established PD stent, which has since
been surgically repaired.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
Patient diet: clear liquid diet.
Vitals: assessed every 4 hours, per hospital protocol.
Activity: patient ambulates once per hour to promote circulation and improve mobility; SCD socks are worn to
promote circulation during times where ambulating is not possible.
Scheduled diagnostic tests: ERCP completed 2/16/17 with no complications, no further diagnostic tests scheduled
at this time.
Consults: Per patient request, patient will meet with pain management doctor. Patient is encouraged to meet with
registered dietician during hospital stay to discuss diet.

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

1. Acute pain related to irritation of the inflamed pancreas as evidenced by patient stating complaints of severe acute pain.

2. Ineffective health maintenance related to deficient knowledge concerning medication.

3. Nausea related to irritation of the gastrointestinal system as evidenced by patient stating he is experiencing nausea.

4. Imbalanced nutrition: less than body requirements related to inadequate dietary intake as evidenced by patient’s diet.

5. Risk for chronic sorrow related to chronic illness.

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± 15 CARE PLAN
Nursing Diagnosis: Acute pain related to irritation of the inflamed pancreas as evidenced by patient stating complaints of severe acute pain.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will report that pain Assess the patient for pain presence “Pain assessment is as important as Patient’s pain was assessed fully
management regimen achieves every 3 hours, and after physiological vital signs. Acute every 3 hours, as well as after
comfort-function goal (0-5/10) interventions or procedures that are pain should be reliably assessed periods of activity. Patient stated
without side effects by end of shift. likely to cause pain, both during both at rest (important for comfort) pain increased during activity and
activity and rest. and during movement (important remained constant at rest.
for function and decreased patient
risk of cardiopulmonary and
thromboembolic events)” (Ackley,
2014, p. 577).
Administer supplemental analgesic “An order for PRN supplemental Hydromorphone (Dilaudid),
doses as ordered to keep the analgesic doses between regular ketorolac (Toradol), and oxycodone
patient’s pain level at or below the doses is essential in providing (Roxiodone) were made available
comfort-function goal (0-5/10). comprehensive pain management” to the patient PRN to assist with
(Ackley, 2014, p. 580). pain. Patient requested
hydromorphone (Dilaudid) as
scheduled and stated it helped to
relieve some of the pain.
In addition to administering “Cognitive-behavioral strategies Heat packs were offered to patient
analgesics, support the patient’s use can restore the patient’s sense of to assist in abdominal pain, patient
of nonpharmacological methods to self-control, personal efficacy, and was encouraged to watch television
help control pain, such as active participation in his/her own or use mobile device to distract self
distraction, imagery, relaxation, care” (Ackley, 2014, p. 581). from pain. Patient stated that
and application of heat and cold. application of heat was the most
useful nonpharmacological method.
Patient will notify member of the Assess pain intensity level using a “The first step in pain assessment Patient rated pain 9/10 at worst and
health care team promptly for pain valid and reliable self-report pain is to determine if the patient can tolerable and manageable at 5/10.
intensity level that is consistently tool, such as the 0-10 numerical provide a self-report. Ask the Patient stated without pain
greater than the comfort-function pain rating scale. patient to rate pain intensity or medications, pain was at 9/10.
goal (0-5/10), or occurrence of side select descriptors of pain intensity Patient described 5/10 as “what I
effects during length of hospital using a valid self-reporting pain live with on a daily basis.”
stay. tool” (Ackley, 2014, p. 577).
University of South Florida College of Nursing – Revision September 2014 14
 Explain to the client the pain
management approach, including
pharmacological and
nonpharmacological interventions,
the assessment and reassessment
process, potential side effects, and
the importance of prompt reporting
of unrelieved pain.
Teach and implement
nonpharmacological interventions
when pain is relatively well
controlled with pharmacological
interventions.
“One of the most important steps
toward improved control of pain is
a better client understanding of the
nature of pain, its treatment, and
the role the client needs to play in
pain control” (Ackley, 2014, p.
579).
“Pain causes cognitive impairment.
Nonpharmacological interventions
should be used to supplement, not
replace, pharmacological
interventions” (Ackley, 2014, p.
581).
Patient was educated on
nonpharmacological interventions
such as distraction, relaxation, and
application of heat to ease pain.
Patient verbalized understanding on
the importance of reporting
unrelieved pain.
Teachings were conducted after
administration of pain medications.
Patient verbalized gratefulness of
relieving pain before beginning
teachings, as it “made it easier to
focus.”

Include a minimum of one

Long term goal per care plan

Nursing Diagnosis: Ineffective health maintenance related to deficient knowledge concerning medication.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will follow mutually agreed Refer the patient to appropriate “When appropriate referrals are Patient was referred to pain
on health care maintenance plan services as needed. missed or delayed, patients often management doctor with scheduled
after discharge from the hospital. experience poor outcomes, appointments to maintain the refill
including complications, prescription of pain medications
psychologial distress, and hospital used to assist patient with acute and
readmissions” (Ackley, 2014, p. chronic pain.
413).
Develop collaborative “Multidisciplinary and Patient’s care team includes
University of South Florida College of Nursing – Revision September 2014 15

Patient will discuss fear of or
blocks to implementing health
regimen by end of shift.
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
University of South Florida College of Nursing – Revision September 2014
multidisciplinary partnerships.
Assess the patient’s feelings,
values, and reasons for not
following the prescribed plan of
care.
Assess for family patterns,
economic issues, and cultural
patterns that influence compliance
with a given medical regimen.
Identify support groups related to
the disease process.
multifactorial interventions are
likely to be more effective in
achieving desired outcomes”
(Ackley, 2014, p. 414).
“Patients often want to have more
influence on decision-making in
the care than they are actually
afforded” (Ackley, 2014, p. 412).
“There are marked differences in
use of health care services among
different cultural groups” (Ackley,
2014, p. 413).
“Individuals who attend support
groups demonstrate improved
disease management and enhanced
quality of life” (Ackley, 2014, p.
413).
primary care physician, pain
management doctor,
gastrointestinal doctor, nurses, and
family/friends.
Patient was asked in a therapeutic
manner the reasons for not
following the prescribed plan of
care. Patient stated it is cost-related
due to not being able to afford the
medications and not having health
insurance.
Patient stated that economic issues
are the reason for lack of health
regimen compliance.
Patient verbalized gratefulness for
the support group referrals. Patient
stated that he believes it may help
in managing his disease.
16
□Dietary Consult Explain to patient nutritional needs and how to meet them
□PT/ OT
□Pastoral Care
□Durable Medical Needs Patient requests to meet with Pain Management team for prescription to assist with the abdominal pain
□F/U appointments Patient will need to meet with Pain Management doctor for refills on prescriptions
□Med Instruction/Prescription Patient will need to be instructed on the proper method of taking medication
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 17

 References

Ackley, B. J. (2014). Nursing diagnosis handbook (10th ed.), St. Louis, MO: Elsevier Mosby

Adler, G., & Glasbrenner, B. (1993, December). Pathophysiology of acute pancreatitis. Retrieved March 02, 2017, from
https://www.ncbi.nlm.nih.gov/pubmed/8119636

Food Tracker. (n.d.). from https://www.supertracker.usda.gov/foodtracker.aspx

Kee, J. L., Hayes, E. R., McCuistion, L. E. (2015). Pharmacology: a patient­centered nursing process approach (8th ed.). St. Louis, 
MO: Elsevier Saunders.

McLeod, S. (2013). Erik Erikson. from http://www.simplypsychology.org/Erik­Erikson.html

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University of South Florida College of Nursing – Revision September 2014 19