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UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Marc-Allen Dy . Assignment

UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL

Student: Marc-Allen Dy

 

.

Assignment Date: 10/25/2016

1 PATIENT INFORMATION

Agency: LRH

Patient Initials: GWP

Age:77

Admission Date: 10/08/2016

Gender: Male

Marital Status: Married

Primary Medical Diagnosis: Lung cancer, pleural effusion, hospital acquired pneumonia, UTI, leukocytosis

Primary Language: English

 

Level of Education: Master’s Degree in Biology

Other Medical Diagnoses: (new on this admission) Lung cancer

Occupation (if retired, what from?): High school biology teacher/principal

 

Number/ages children/siblings: 3 children, 1 brother

 
   

Served/Veteran:

Code Status: FULL

If yes: Ever deployed? Yes or No

Living Arrangements: Lives with his wife, wife takes care of him, there are no stairs, wife does not have Alzheimer’s and helps with

Advanced Directives: None If no, do they want to fill them out? No

 

Surgery Date:

Procedure:

Culture/ Ethnicity /Nationality: Russian

 

Religion: Roman Catholic

Type of Insurance: Coventry

1 CHIEF COMPLAINT: shortness of breath, pain to right groin, and urinary hesitancy

UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Marc-Allen Dy . Assignment

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) The patient is a 77 year old male who came in to the ER for shortness of breath. The patient has PMH of BOOP (bronchiolitis obliterans with organizing pneumonia), tongue cancer, renal TCC, and stated the shortness of breath has worsened over the past 2 weeks. The patient was previously admitted for right lower lobe community acquired pneumonia and was discharged on Levaquin and nebulizers. Patient cannot walk more than 5-8 steps without getting fatigued and winded. Activity tolerance has become progressively worse. Patient states the shortness of breath is of moderate intensity, denies CP, and no fever. Patient has a history of smoking, and smoked for 23 years and one pack every day. Patient has urinary hesitancy over the past week with pain in the right groin. The patient had a ventilation perfusion scan for pulmonary embolism. Patient denies any history of blood clots, but has past medical history of cancers and surgeries such as TURBT and removal of lesion of the tongue.

UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Marc-Allen Dy . Assignment

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

Date

Operation or Illness

7/14/2015

Bladder resect urethral tumor cysto

7/14/2015

Bladder installation cysto

12/02/2014

Bladder trans urethral cysto

12/02/2014

Bladder installation cysto

12/02/2014

Bladder resect transurethral tumor cysto

11/11/2014

Bladder reset transurethral tumor cysto

11/11/2014

Bladder installation cysto

 

Prostate resect transurethral cysto

04/30/2014

Set lung biopsy

 

Bladder surgery, removal, pilonidal cyst, cystoscopy, tonsillectomy with adenoidectomy, cataract removal

 

Cataracts, hypercholesterolemia (Crestor 40mg daily), hypothyroidism (Levoxyl 20mg bid, thyroid condition), degenerative disorder of the macula, cataracts, carcinoma of the kidney, bladder cancer, kidney cancer, carcinoma of the bladder, tongue cancer, chronic kidney disease stage 3, arthritis, myocardial infarction

 

BOOP, arteriosclerosis of aorta, atypical mycobacterial of the lung, MI with percutaneous coronary angiogram (Timolol 5mg), bronchiectasis, history of bladder surgery, prostate surgery, tubercular adenoma of the colon

 2 FAMILY Cause MEDICAL of HISTORY Death (if applicable) Father X X Mother X X
 2
FAMILY
Cause
MEDICAL
of
HISTORY
Death
(if
applicable)
Father
X
X
Mother
X
X
X
X
Brother
X
Sister
relationship
relationship
relationship
Comments: Include age of onset
Age (in years)
Alcoholism
Environmental
Allergies
Anemia
Arthritis
Asthma
Bleeds Easily
Cancer
Diabetes
Glaucoma
Gout
Heart Trouble
(angina, MI, DVT etc.)
Hypertension
Kidney
Problems
Mental Health
Problems
Seizures
Stomach Ulcers
Stroke
Tumor

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

YES

NO

Routine childhood vaccinations

U

   

Routine adult vaccinations for military or federal service

U

   

Adult Diphtheria (Date)

U

   

Adult Tetanus (Date) Is within 10 years?

U

   

Influenza (flu) (Date) Is within 1 years?

U

   

Pneumococcal (pneumonia) (Date) Is within 5 years?

U

   

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 REACTIONS

Causative Agent

Type of Reaction (describe explicitly)

 

NKDA

 
   

Medications

   
   
     
   
 

NKDA

 

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) Mechanism of disease: Lung cancer begins in the same way other cancers start, by carcinogens entering the body, and progressively evolving into mutations that alter the body’s structure. According to Clin. Chest Med (2011), “cigarette smoke both initiates and promotes carcinogenesis (Clin Chest Med p.3)” The root of lung cancer is caused by genetic mutations caused by smoking, which is initiated by carcinogens. Smoke accumulates in the lungs and causes mutations to evolve because of chronic irritation. Two types of cancers are developed by carcinogenesis: SCLC (small-cell lung cancers) and NSCLC (non-small cell lung cancers). SCLC metastasizes faster than NSCLC, but does well with chemotherapeutic treatments. On the other hand, NSCLC metastasizes slowly, but also responds poorly to chemotherapy. SCLC develops into a central tumor, and NSCLC develops into a peripheral tumor. The symptoms of the tumors vary by location and the type. Some lung cancers can show symptoms of either peripheral, central, or both. According to the Cleveland Medical Center (2016), smoking is the number one cause of lung cancer, which causes about 85% of cases (Cleveland Medical Center p.2) The risk for lung cancer increases with smoking use. Other risk factors such as environmental exposures include pollution, asbestos, tar, soot, and metals such as arsenic, chromium and nickel. Lung cancer is diagnosed by taking a biopsy after a CT scan or X-ray of the chest. According to the UK Cancer Research Center (2014), if the patient reaches stage 4, “only 1 out of every 100 people will survive 5 years or more after diagnosis” (UK Cancer Research Center p.3) Treatment of lung cancer depends on the stage the cancer has reached. Stage 1 has the most options with, chemotherapy, radiotherapy, and surgery. Stages 2 and 3 have the combined therapy of chemoradiotherapy along with surgery, stage 4 only has chemotherapy.

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 acetylcysteine

Concentration 400mg/0.4mL

 

Dosage Amount 400mg

Route solution, NEB, med nebulizer, oral

Frequency qid

 

Pharmaceutical class Acetaminophen antidote, mucolytic agent

Home

Hospital

or

Both X

Indication - Adjunctive therapy in patients with abnormal, viscid, or inspissated secretions in diseases such as chronic emphysema, bronchitis, tuberculosis, pneumonia, asthma, cystic fibrosis (used to thin mucus) , and for acetaminophen poisoning

Adverse/ Side effects - edema, flushing, tachycardia, rash, pruritus, uticaria, nausea, vomiting, anaphylaxis, pharyngitis, rhinorrhea, angioedema, bronchospasm, chest tightness, dizziness, dyspnea, hypotension, respiratory distress, hypersensitivity, bronchitis

Nursing considerations/ Patient Teaching report any signs of shortness of breath, allergic reactions, black, tarry, or bloody stools, throwing up blood or any liquid that is coffee colored, or any dizziness or passing out

Name albuterol (2.5mg/0.5mL)

Concentration 2.5mg/0.5mL

 

Dosage Amount 2.5mg

Route solution, NEB, med neb, inhaler, oral

Frequency qid

 

Pharmaceutical class Beta2 agonist

Home

Hospital

or

Both X

Indication treatment of bronchospasm in patients with reversible obstructive airway disease; prevention of exercise-induced bronchospasm, asthma, hyperkalemia, COPD

Adverse/ Side effects CNS excitement, nervousness, tremor, upper respiratory infection, rhinitis, bronchospasm, pharyngitis, exacerbation of asthma, tachycardia, hypertension, chest pain, palpitations, headache, dizziness, insomnia, anxiety, ataxia, depression, drowsiness, rigors, , malaise, diaphoresis, skin rash, uticaria, pallor, throat irritation, respiratory tract disease, hypersensitivity reaction, nasopharyngitis, sinusitis, dyspnea, otitis media, muscle weakness

Nursing considerations/ Patient Teaching Store at room temperature, protect from light, store in a dry place, keep all drugs in a safe place, check with pharmacist before use, shake well before use, prime the inhaler before use, do not use near an open flame or while smoking., Do not take more of this drug or use it more often than told, call the doctor if the normal dose does not work, watch your blood sugar if you have diabetes, or are pregnant talk with your healthcare provider. Report any signs of allergy, muscle weakness, pain, or cramps, chest pain, feelings of nervousness or excitability, headache, dizziness, or passing out

Name azithromycin

Concentration 500mg/500mg

 

Dosage Amount 500mg

Route tab, oral, MV

Frequency qid

Pharmaceutical class Antibiotic, macrolides

Home

Hospital X or

Both

Indication Treatment of otitis media, community acquired pneumonia, bacterial exacerbation of COPD, acute bacterial sinusitis, skin infections, urethritis, and cervicitis

Adverse/ Side effects Loose stools, vomiting, chest pain, palpitations ,diarrhea, nausea, skin rash, dermatitis, pruritus, skin photosensitivity, abdominal pain, anorexia, flatulence, vaginitis, genital candidiasis, pain at the injection site, inflammation, oral candidiasis, genital candidiasis, increased serum ALT, increased serum AST, increased serum creatinine, bronchospasm

Nursing considerations/ Patient Teaching do not use this drug longer than needed, if taking warfarin, report any reactions to the drug, the drug may cause an abnormal heartbeat, report to your doctor if you are 65 or older, pregnant, or breastfeeding, call your doctor if you have any of the following: tachycardia, change in hearing, chest pain or pressure, tinnitus, dizziness or passing out, trouble swallowing or speaking, fever, swollen gland, vaginal itching or discharge diarrhea

Name timolol

Concentration 1 tab/5mg

 

Dosage Amount 5mg

Route 1 tab, oral

Frequency bid

Pharmaceutical class Antihypertensive, Beta blocker; nonselective

Home

Hospital

or

Both X

Indication treats hypertension and angina, reduces heart attack and death after an MI, prevention of migraines

 

Adverse/ Side effects Angina pectoris, arrhythmia, cardiac arrest, cardiac failure, cerebral ischemia, CVA, edema, heart block, hypotension, palpitation, bradycardia, fatigue, dizziness, dyspnea

Nursing considerations/ Patient Teaching do not stop taking this drug suddenly, increases chest pain and risk of a heart attack, avoid driving, have blood works done, check blood pressure and heart rate, report to the doctor if having signs of dizziness, shortness of breath, chest pain, slow heartbeat, abnormal heart, muscle weakness, or feeling cold

Name ipratropium

Concentration 2.5mL/50mcg

 

Dosage Amount 500mcg

Route solution, NEB, med neb

Frequency qid

Pharmaceutical class Anticholinergic drug

Home

Hospital

or

Both X

Indication maintenance treatment of bronchospasm associated with COPD, and chronic bronchitis and emphysema

 

Adverse/ Side effects Bronchitis, exacerbation of COPD, sinusitis, headache, dizziness, dyspepsia, nausea, xerostomia, dysgeusia, urinary tract infection, back pain, dyspnea, flu-like symptoms, cough, rhinitis, upper respiratory tract infection

Nursing considerations/ Patient Teaching monitor respiratory status, report treatment failure, report any change in eye sight, eye pain, or eye irritation, report any inability to pass urine, pain when passing urine, dizziness or passing out, tachycardia, abnormal heartbeat, mouth irritation or mouth sores

Name levothyroxine (Levoxyl)

Concentration 1 tab/20mg

 

Dosage Amount 20mg

Route Oral

Frequency bid, abcr

 

Pharmaceutical class Thyroid product

Home

Hospital

or

Both X

Indication replacement or supplemental therapy for all forms of hypothyroidism (primary, secondary, and tertiary)

 

Adverse/ Side effects Angina, cardiac arrest, cardiac arrhythmia, congestive heart failure, flushing, hypertension, myocardial infarctions, palpitations, tachycardia, anxiety, fatigue, headache, heat intolerance, hyperactivity, insomnia, irritability, myasthenia, weight loss, abdominal cramps, diarrhea, dysphagia, vomiting, infertility, hypersensitivity, tremor, dyspnea, fever

Nursing considerations/ Patient Teaching Monitor pulse before each dose, monitor for adverse effects, the drug may take several weeks to take effect, the drug may cause osteoporosis with long-term use, can interact with other drugs, and if you are 65 years old or older, pregnancy, or breast-feeding, do not use this drug

Name tamsulosin

Concentration 1 cap/0.4mg

 

Dosage Amount 0.4 mg

Route 1 cap, oral

Frequency daily

 

Pharmaceutical class Alpha1 blocker

Home

Hospital

or

Both X

Indication treatment of BPH (benign prostatic hyperplasia), bladder obstruction, and ureteral calculi

 

Adverse/ Side effects Orthostatic hypotension, headache, dizziness, ejaculation failure, infection, rhinitis, drowsiness, diarrhea, weakness, back pain, blurred vision, pharyngitis, cough, sinusitis

Nursing considerations/ Patient Teaching monitor for signs of orthostatic hypotension, take BP lying down, report a systolic pressure drop of more than 15mm Hg or a heart rate of more than 15 beats, monitor if the patient is taking warfarin, report to the doctor if there feeling any signs of dizziness or passing out, any blurred vision, chest pain, abnormal heartbeat, fever or chills, sore throat, shortness of breath, or a painful erection

Name rosuvastatin

Concentration 2 tab/40mg

 

Dosage Amount 40mg

Route Oral

Frequency daily

 

Pharmaceutical class Antilipidemic, HMG-CoA reductase inhibitor

Home

Hospital

or

Both X

Indication used for hypercholesterolemia, hyperlipidemia, and hypertriglyceridemia, reduces LDL cholesterol, risk of stroke, myocardial infarction, and cardiovascular disease

Adverse/ Side effects myalgia, headache, dizziness, nausea, constipation, arthralgia, weakness

 

Nursing considerations/ Patient Teaching monitor for myopathy, notify the provider if creatinine level is elevated, monitor for any cardiovascular response especially in patients with hypertension or heart disease, do not take antacids, do not breastfeed, females should use contraception to prevent pregancies

Name isosorbibe dinitrate

Concentration 1 tab/20mg

 

Dosage Amount 20mg

Route oral

Frequency bid

 

Pharmaceutical class Antianginal agent, vasodilator

Home

Hospital

or

Both X

Indication prevention of angina due to coronary artery disease, not used for acute angina episodes

 

Adverse/ Side effects Hypotension, orthostatic hypotension, syncope, dizziness, headache

 

Nursing considerations/ Patient Teaching do not administer around the clock, monitor effectives, change positions slowly, lie down at any indication of lightheadness or signs of fainting, do not drink alcohol or breast feed while taking this drug

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.

Diet ordered in hospital?

Cardiac

Analysis of home diet (Compare to “My Plate” and

Diet patient follows at home? Heart healthy diet

Consider co-morbidities and cultural considerations):

24 HR average home diet: Heart healthy diet

The patient’s diet consists on 50% refined whole grains,

Breakfast: Cereal (Cheerios)

0% of vegetables, 4% of fruits, 51% of dairy, and 298%

 

of protein. I would recommend the patient have another

Lunch: Sandwich, roast beef, cheese, lettuce, tomato, iced tea

bowl of cereal in the morning, as well as some fruits and

 

vegetables during lunch and dinner. To increase the

Dinner: salmon and swordfish

percentage of fruits and vegetables, I would also suggest

 

that the patient have fruits and vegetables for snacks as

Snacks: N/A

well. The patient’s daily diet consists of high amounts of

 

sodium (2908mg out of 2300mg), and fat (20g out of 22g). Both must be lowered to prevent risk of repeated heart disease. I would recommend the patient to reduce in sodium and fat intake by eating more vegetables instead of meats and fish, or suggest alternative cooking methods that reduce the amount of fat and sodium.

Liquids (include alcohol): 4 glasses of water, and 2 ice teas

 
   
Use this link for the nutritional analysis by comparing the patients 24 HR average home diet

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? “My wife helps me when I am sick. She makes sure I take my medications and takes

me to the hospital when I am feeling unwell.”

How do you generally cope with stress? or What do you do when you are upset?

“Whenever I am stressed, I go to church and pray. I pray that the Lord will help heal my illness and provide comfort for

me.” “I go to church to meditate when I am upset or distressed.”

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

“I was recently diagnosed with lung cancer.”

+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? ______________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:

 

Erikson’s stage of psychosocial development:

Erikson’s stage of psychosocial development:

Trust vs.

Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt

Mistrust

Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt

Autonomy vs.

Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt

Doubt & Shame

Initiative vs.

Initiative vs.

Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt

Guilt

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

X 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: Ego Integrity-

“the adult feels a sense of fulfillment about life and accepts death as an unavoidable reality” (Cramer 1997, p.1)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

According to Saul McLeod, the stage of Ego Integrity is the stage in life where “we contemplate our accomplishments

and are able to develop integrity if we see ourselves leading a successful life” (McLeod p.6). I determined he would be in

this stage

because of the multiple cancers. The patient appeared calm, collected, and nonchalant about his disease state. After his

first diagnoses of cancer, I concluded he has become somewhat desensitized to his sickness and has accepted where he is

in life. The patient has lived a full life with his wife and children, and he appeared calm despite his recent diagnosis of

lung cancer. The patient was not in despair and showed no signs of depression, anxiety, or any bitter feelings.

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life The patient has/had

lung cancer, bladder cancer, tongue cancer, and kidney cancer. Through my patient’s condition, I concluded that he is in

Ego Integrity stage because the cancer has metastasized all over his body.

+3 CULTURAL ASSESSMENT:

“What do you think is the cause of your illness?”

“Aging. I’m getting old and my body is telling me almost time for me to go.”

What does your illness mean to you?

“My illness means that I have to be in the hospital for a long time.”

+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?

No __________________________________________________________________

__

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?

__________

Yes

__________

When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or

an unintended pregnancy? _None _________________________________

How long have you been with your current partner?_+50 years _______________________________

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

Yes,

bladder cancer

__

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?

No

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

“Religion is an important part of my life. It helps me cope and it comforts me when I am sad.” “I go to mass often with my wife _and

we pray for Him to give us strength and healing.”

____________________________________________________________________________________________________

______________________________________________________________________________________________________

Do your religious beliefs influence your current condition?

“Yes, I believe God has a purpose and plan for us all. I think my illnesses are a part of his plan for me.”

_______________________________________________________________________________

______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
1.
Does the patient currently, or has he/she ever smoked or used chewing tobacco?
Yes
No X
If so, what?
How much?(specify daily amount)
For how many years?
37 years
Yes, smoked cigarettes
2 packs a day
(age
17
thru
54
)
If applicable, when did the
Pack Years: 37
patient quit?
1993, 23 years ago
Does anyone in the patient’s household smoke tobacco? If
Has the patient ever tried to quit?
so, what, and how much?
If yes, what did they use to try to quit?
2.
Does the patient drink alcohol or has he/she ever drank alcohol?
Yes X
No
What? Beer
How much? 1 can
For how many years? Current
Volume: 12 fl. Oz.
(age
thru
)
Frequency: 1-2 times a month
If applicable, when did the patient quit?
3.
Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
Yes
No X
If so, what?
N/A
How much? N/A
For how many years? N/A
(age
thru
)
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes
No X
N/A
4.
Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks Never, none
5.
For Veterans: Have you had any kind of service related exposure? None

10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? “Not good.”

Patient reports no recent weight loss or gain

Integumentary: No rash, pruritus, abrasions, burns, bruises, pressure ulcers, psoriasis, hives, skin infections, uses sunscreen

HEENT: Normocephalic, hard of hearing, has vision problems, oral mucosa is moist, no pharyngeal erythema, blurred vision, or double vision, glaucoma, sinus pain or infections, epistaxis, post-nasal drip, oral/pharyngeal infection, not dental problems, brush teeth daily, and visits dentist every 6 months, and screened for vision once a year

Pulmonary: Patient admits shortness of breath, bronchitis and pneumonia patient denies cough or sputum, asthma, emphysema, tuberculosis, last chest X-ray was 10/16/2016

Cardiovascular: Patient admits hypertension, hyperlipidemia, chest pain, angina, myocardial infarction (1999), CVD/PVD, no history or CHF, murmur, thrombus, rheumatic fever, myocarditis, arrhythmias, and last EKG was 10/16/2016

GI: Patient denies nausea, vomiting, or diarrhea, constipation, GERD, indigestion, hemorrhoids, yellow jaundice, pancreatitis, colitis, diverticulitis, appendicitis, abdominal abscess, irritable bowel syndrome, cholecystitis, gastritis, ulcers, blood in the stool, hepatitis, last colonoscopy was March 2016

GU: Patient admits nocturia, dysuria, and denies hematuria, polyuria, kidney stones, kidney infections, and urinates 3 times a day

Women/Men Only: Patient denies infection of genitalia/prostate, prostate was checked every year until surgery, and last prostate exam was in 2014, patient has history of BPH and urinary retention

Musculoskeletal: Weakness, decreased strength, no tenderness, deformity, injuries or fractures, pain, gout osteomyelitis, arthritis

Immunologic: Patient denies any chills with severe shaking, night sweats, fever, HIV or AIDS, lupus, rheumatoid arthritis, sarcoidosis, tumor, life threatening allergic reaction, enlarged lymph nodes

Hematologic/Oncologic: Patient admits cancer, but patient denies any bruising, bleeding, or anemia, or any blood transfusions

Metabolic/Endocrine: Patient admites hypothyroidism but denies any history of diabetes, hot or cold intolerances, osteoporosis

Central Nervous System: Patient denies an CVA, dizziness, severe headaches, migraines, ticks or tremors, encephalitis, meningitis

Mental Illness: Patient denies any mental illnesses such depression, schizophrenia, anxiety, bipolar

Childhood Diseases: Patients denies any childhood illnesses such as measles, mumps, polio, scarlet fever, chicken pox

 
 
 
 
 
 
 
 

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

No

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

No

±10 PHYSICAL EXAMINATION:

General survey _Patient is a 77 year old male who is of normal weight and no apparent signs of distress and is

alerted and oriented x3 _______________________________________________________________________________

Height ___

172cm

 

_________

Weight

___

70.72kg _______

BMI ___

23.9

________

Pain (include rating and

 

location)

_____

3,

right lower abdomen

______________

Pulse

__

94 _____

Blood Pressure (include

location)

_______

98/52

left_arm

_____________

Temperature

(route taken)

______

36.8

oral

______

Respirations

___

18

_________

SpO2 _______

98

__________

Room Air or O2

nasal

_______

cannula 2L

_______

Overall Appearance

Patient

is cleaned, hair combed, dressed appropriately for setting and temperature, maintains

eye contact, no obvious

handicaps ______________________________________________________________________________

Overall Behavior_Patient is awake, calm, relaxed, interacts well with others, judgment intact,

_________________________________________________________________________________

Speech

___

Patient

talks with clean, crisp diction

___

_____________________________________________________________________________________

Mood and Affect_Patient is pleasant, cooperative, cheerful,

talkative __________________________________________________________________________________

Integumentary_Patient’s skin is warm, dry, and intact, skin turgor is elastic, no rashes, lesions, or deformities, nails

are without clubbing, capillary refill is less than 3 seconds, hair is evenly distributed and

neat __________________________________________________________________________________

IV Access

Peripheral

IV is 22in on the right forearm with no redness, edema or discharge, normal saline infusing

into IV site_

_____________________________________________________________________________________

HEENT_Patient is symmetric, no pain in the sinus region, no pain, clicking of TMJ, trachea is midline, thyroid not

enlarged, no palpable lymph nodes, sclera is white and clear with discharge, eyebrows, eyelids, orbital area,

eyelashes, and lacrimal glands symmetric without edema or tenderness, pupils are equal, round reactive to light,

peripheral vision is intact, EOM intact through 6 cardinal fields without nystagmus, ears are symmetric without

lesions or discharge, whisper test heard, nose is without lesions or discharge, lips, buccal mucosa, floor of mouth and

tongue pink and moist without any

lesions __________________________________________________________________________________________

Pulmonary/Thorax

Respirations

are regular and unlabored, tranverse to AP ratio 2:1, chest expansion symmetric,

percussion resonant throughout all lung fields, dull towards, sputum production is white, lung sounds are dull in all

extremities ______________________________________________________________________________

Cardiovascular

No

lifts, heaves, or thrills noted, S1, S2 audible, calf pain bilaterally negative, pulses bilaterally

equal = 3, apical pulse =3, carotid pulse =3, brachial pulse=3, radial pulse=3, femoral pulse=3, popliteal pulse=3,

DP=3, PT=3, no temporal or carotid bruits, edema =0, extremities are warm with capillary refill less than 3 seconds

_________________________________________________________________________________

GI

__

Bowel

sounds active x4; no bruits auscultated, no oreganomegaly, percussion dull over liver and spleen and

tympanic over stomach and intestine, abdominen non-tender to palpation, last bowel movement 10/17/2016, formed,

brown, light brown, no nausea, emesis, and genitalia is clean, moist, without discharge lesions or

odor ______________________________________________________________________________________________

GU

Urine

output is clear, color is pale yellow, I/O 300mL, and goes to the bathroom with

assistance ___________________________________________________________________________________________

_

Musculoskeletal

Full

ROM intact in all extremities without crepitus, strength is bilaterally equal at 5/5 RUE, 5/5

LUE, 3/5 RLE and 3/5 LLE, vertebral column without kyphosis or scoliosis, neuromuscular status intact: peripheral

pulses palpable, no pain, no pallor, paralysis, or

parasthesia ___________________________________________________________________________________

Neurological Patient was alert, oriented to person, place, time and date, CN 2-12 grossly intact, sensation intact to

touch, pain and vibration, Romberg’s negative, stereognosis, graphesthesia, and proprioception intact, gait smooth,

with symmetric length of the stride, DTR: triceps +2, brachioradial, +2 patellar, +2 achilles, ankle clonus negative,

Babinski negative

±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):

The patient had chest X-rays on 10/08/2016 to test if there were any signs of pulmonary embolism as the possible cause for

the shortness of breath. Chest X-rays were negative and then a USN Doppler was done on 10/12/2016 to the lower

extremities for pulmonary embolism. The Doppler was negative, and did not find any PE. A CT needle biopsy was taken

from the patient on 10/12/2016, and testing positive for lung cancer. The patient had pleural drainage on 10/16/2016

because the patient had pleural effusion in the lungs. The patient had thoracentesis as a follow up on 10/17/2016 to confirm

the finding of cancer, which atypical bilateral masses were found in the right lung.

Lab

Dates

Trend

Analysis

WBC

 

White blood cell count is

White blood cells are sent

9.7k

10/17/2016

decreasing, rapidly,

out to fight infections of

9.1k

10/18/2016

indicating cancer, or an infection.

the body. A decreased white blood cell count means the white blood cells are being destroyed by the infection or cancer.

BUN

 

Patient’s BUN level

BUN, or blood urea

41

10/17/2016

keeps rising, and

nitrogen is an indicator of

49

10/18/2016

continues to rise. The

kidney function. High

Normal (7-20)

BUN rising upwards indicates failure in the kidneys.

BUN indicates reduced kidney function. The patient has PMH of chronic kidney disease stage 3, which indicates the patient’s kidneys are losing the ability to excrete BUN.

Creatinine

   

Creatinine, along with

  • 2.2 10/17/2016

Patient’s creatinine level

BUN, is an indicator of

  • 2.8 10/18/2016

continues to rise, which

kidney function.

Normal (0.6-1.2)

as an indication of increased protein

High creatinine means the kidneys are not

     

consumption and inability to excrete creatinine.

functioning properly and can increase with dehydration, low blood volume, or consumption of large amount of protein.

 

Neutro Auto

 

The neutrophil

Neutrophils are the most

84.7%

10/17/2016

percentage is decreasing,

abundant type of white

82.9%

10/18/2016

meaning white cells are

blood cells. Decreased

Normal (54 to 62%)

being eradicated by an infection or cancer.

neutrophil percentage indicates a progression of the infection or cancer overcoming the body’s defenses.

Abs Neutrophil

 

The neutrophil

Neutrophils are the most

  • 1.1 10/17/2016

percentage is decreasing,

abundant type of white

  • 0.6 10/18/2016

meaning white blood cells are being eradicated by an infection or cancer.

blood cells. Decreased neutrophil percentage indicates a progression of the infection or cancer overcoming the body’s defenses.

Abs Lymphocyte

 

The increased percentage

Lymphocytes are an

0.60k/.mcL

10/17/2016

essential part of the

0.60k/mcL

10/18/2016

may be due to cancer or bacterial infection.

immune system and help fight off infection. If there is an increase in lymphocytes, there is an infection or cancer present.

       
       
       

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) On admission, the patient had a NMR ventilation/perfusion scan to see if a pulmonary embolism was the cause of

the patient’s shortness of breath. NMR was negative, so the patient had a USN Doppler venous bilateral on the lower extremities to test if the patient had a pulmonary embolism that began in the lower extremities. The pulmonary embolism was negative, but there was no The patient had a CT needle biopsy on the 10/12/2016 to check if the patient had lung cancer. The biopsy raised suspicion for cancer. While the biopsy was being processed, the patient had a CT scan without contrast on 10/16/2016 to check for cancer. The biopsy came back positive for lung cancer. The patient had a VAS pleural drainage on 10/17/2016 to clear fluid from the lungs because the patient has a history of pleural effusion. In addition to the VAS pleural drainage, the patient had a thoracentesis on 10/17/2016 to confirm the diagnosis of lung cancer. The patient is on a cardiac diet because of previous myocardial infarction in 1999. The patient also have a history of hypertension and hyperlipidemia, so

this diet is ordered to lower sodium and fat intake. The patient’s vitals are checked every 8 hours instead of once every shift because the patient must be monitored for changes in blood pressure or respirations. Patient is seen by physical therapy to help maintain mobility, because the patient has weakness in the lower extremities and gets fatigued easily.

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

1.Ineffective breathing pattern related to pleural effusion as evidenced by exertional dyspnea, fatigue, and bilateral atypical

masses in the lungs

2.

Chronic pain related to treatment of metastatic tumor as evidenced by patient’s self-report of pain, history of bladder,

kidney, and tongue cancer

 
 

3.

Urinary retention related to BPH, as evidenced by low urine output less than 30mL, elevated BUN of 41, and creatinine

of 2.2

 
 

4.

Risk for falls related to impaired mobility

5.

± 15 CARE PLAN

Nursing Diagnosis: Ineffective Breathing Pattern related to pleural effusion

Patient Goals/Outcomes

Patient Goals/Outcomes Nursing Interventions to Achieve Goal Rationale for Interventions Provide References Evaluation of Goal on

Nursing Interventions to Achieve Goal

Rationale for Interventions Provide References

Evaluation of Goal on Day Care is Provided

Patient will maintain a 98% oxygen saturation level

Note depth, rate, and frequency, and any difficulty breathing

Respiratory mechanisms are trying to compensate for the lack of oxygen intake

Patient physically shows no signs of difficulty breathing

 

Place the client in a semi to high Fowler’s position to prevent slumping

Placing the client in the semi to high Fowler’s position helps the patient breathe by allowing for more chest expansion, therefore allowing more oxygen to enter in and out of the body. It also helps prevent the patient from choking, but allowing gravity to help pull food downwards

Evaluated by the patient’s reported level comfort and ease of breathing

   
  • I would teach the patient how to

 

Teach the patient how to use incentive spirometer

use the incentive spirometer because it helps with lung expansion and trains the strengthens the lungs which further allows more oxygen to be taken in.

Patient demonstrates how to use incentive spirometer

 

Turn the patient every 2 hours

  • I would turn the patient every 2 hours because it helps breathing by

Patient expresses no difficulty breathing

alleviating pressure on the side and allows the lungs to expand more.

 

Check/adjust nasal cannula when

  • I would check the nasal cannula

Oxygen is checked and set based

entering the room

when entering the room just to make sure the oxygen is set at the

on the provider’s order each time after leaving the room and also

right level and there are no signs of pressure ulcers underneath the equipment

before shift ends

 

Teach deep breathing exercises, such as turn and cough, pursed lip,

Teaching these exercises helps provides maximum ventilation and

Patient demonstrates use of exercises correctly and uses to care

hydration oxygenation for self Include a minimum of one Long term goal per care plan ±2
hydration
oxygenation
for self
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
X
PT/ OT
X
Pastoral Care
□Durable Medical Needs
X
F/U appointments
□Med Instruction/Prescription
□ are any of the patient’s medications available at a discount pharmacy? XYes
□ No
X
Rehab/ HH
X Palliative Care

References

Chaundry, S. Wong, E., Ke, W. Lung Cancer (2012). Retrieved October 23, 2016 from

Choi, H., Mazzone, P., Ha, D. (2014). Lung Cancer. Retrieved October 23, 2016 from

Cleveland Clinic. Lung Cancer. Retrieved October 23, 2016.

Clin. Chest Med. (2011). Lung cancer: epidemiology, etiology, and prevention. Retrieved October 23, 2016.

Cramer

23,
23,

C., Flynn,

2016

October

B., & from
B.,
&
from

LaFave

A.

(1997).

Erik

Erikson’s

8

Stages

of

Psychosocial

Development.

Retrieved

Jewell, T, Judith, M., Ross, H (2016). Blood Differential Test. Retrieved October 26, 2016.

McLeod, S. A. (2013). Erik Erikson. Retrieved from

Shannon. M, K. Shields, C. Stang, B. Wilson. Pearson Prentice Hall Drug Guide (2007). Retrieved October 23, 2016 from http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/I038.html

Mayo Clinic Staff (2016). Creatinine Test. Retrieved October 26, 2016.

Mayo Clinic Staff. (2016). Blood Urea Nitrogen Test. Retrieved October 26, 2016.

Nursing Diagnosis: Ineffective Breathing Pattern (2012). Retrieved October 23, 2016 from

Nurses Nanda (2009). Impaired Gas Exchange Related to Lung Cancer. Retrieved October 23, 2016 from

UK Cancer Research Center UK. Survival statistics for lung cancer. Retriever October 23, 2016.

Wolters Kluwer. Drugs.

https://online.lexi.com/lco/action/home