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COLLEGE OF NURSING
1 CHIEF COMPLAINT:
“This cancer thing. It just spread. And now it is sort of everywhere.”
2
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
5 MEDICATIONS
Name docusate (Docusate sodium) Concentration Dosage Amount 100 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
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
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
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.”
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.”
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.”
+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”
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
Any other questions or comments that your patient would like you to know?
“Nothing”
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
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
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RML CL LLL CL
RLL CL
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
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.
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
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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.
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.
±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.
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