UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Brooke Hyler |

|Fundamental Patient Assessment Tool |Assignment Date: 06/20/14 |

| ( 1 PATIENT INFORMATION |Agency: TGH 2H |

|Patient Initials: D.M. |Age: 52 |Admission Date: 06/19/14 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: English |Prostate Cancer— 185 |

|Level of Education: High School Graduate |Other Medical Diagnoses: (new on this admission) |

|Occupation: Retired; Hospital Kitchen Staff |NONE |

|Number/ages children/siblings: No children. Two Brothers- ages 56(deceased) and 50 | |

| | |

|Served/Veteran: No |Code Status: Full Code |

|Living Arrangements: Lives in an Apartment with his wife. Not a caretaker for anyone. |Advanced Directives: Yes |

| |If no, do they want to fill them out? |

| |Surgery Date: 06/19/14 Procedure: Robotic |

|Culture/ Ethnicity /Nationality: African American |(Davinci) Assisted Laparoscopic Prostatectomy |

|Religion: None |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: “I came to the hospital because I am getting my prostate removed because of my |

|prostate cancer.” “My cancer needs to get removed before it spreads.” |

| |

| |

|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

|A 52 year old male was admitted into the hospital on 06/19/14 for a scheduled robotic (Davinci) assisted laparoscopic |

|prostatectomy due to a Gleason 6 prostate cancer. The patient explains that he was diagnosed with this prostate cancer on |

|3/12/14. The patient reports no symptoms associated with his prostate cancer. Patient explains that he received knowledge |

|of his diagnosis upon an unrelated general examination accompanied by blood testing. Patient denies any pain associated |

|with his cancer, and denies and urinary retention or incontinence, due to the Gleason 6 prostate cancer. Although the |

|patient expresses no associated implications or physical factors in relation to his prostate cancer, the patient reports |

|having had feelings of anxiety about his diagnosis. He reports that his anxiety has been an ongoing emotion since his |

|diagnosis on 03/12/14. On 06/19/14, patient underwent an assisted laparoscopic prostatectomy. Patient explains that the |

|surgery has caused some discomfort with a maximum pain level of 1/10. Patient has not experienced any post-op |

|complications and explains that his anxiety has gotten better, and is virtually non-existent since his operation. |

| |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|As a child (date unknown) |Fractured left leg: Surgery |

|As a child (date unknown) |Tonsillectomy (bilateral) |

|1994 |Appendectomy |

|2004 |Hypertension |

|2011 |Low back pain |

|2011 |Diabetes: Novolog 3 times daily |

|10/21/13 |Colon polyps |

|3/12/14 |Prostate cancer (no chemotherapy, no radiation): Robotic (Davinci) Assisted Laparoscopic Prostatectomy) |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Brother’s lung cancer onset: 2008 |

| |Patient cannot recall any other family medical history onset dates for anything else listed above. |

|( 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 unknown) | | |

|Adult Tetanus (Date unknown) | | |

|Influenza (flu) (Every year) | | |

|Pneumococcal (pneumonia) (Date unknown) | | |

|Have you had any other vaccines given for international travel or occupational purposes? None | | |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Aspirin |Burning sensation in stomach |

| |Compazine |Burning sensation in stomach |

| |Ibuprofen |Burning sensation in stomach |

| |Metronidazole |Itching, burning, and swollen skin |

| | | |

| | | |

|Other (food, tape, latex, dye, |Milk |Nausea (not lactose intolerance) |

|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 patient underwent a robotic assisted laparoscopic prostatectomy due to the presence of a Gleason 6 prostate cancer. |

|Prostate cancer is among the most common of male cancers (Huether, pg. 829). Prostate cancer can occur in any man of |

|any age, but the risk increases with advanced age, especially men 65 years and older. Prostate cancer is generally |

|diagnosed with the screening of the patient’s prostatic specific antigen level to determine the presence of a tumor with the |

|level/stage of the tumor (Huether, pg. 829). The treatment of prostate cancer offers a variety of options. This cancer can |

|be treated with radiation therapy, surgical removal of the entire prostate gland (prostatectomy), or a transurethral resection |

|of the prostate, which removes excess prostatic tissue obstructing urine flow (Huether, pg. 830). Prostate cancer begins |

|with a prostatic intraepithelial neoplasia (PIN), which can develop into adenocarcinomas with increasing age. Due to the |

|fact that prostate cancer can worsen with age, it is crucial for men to get a PSA screening to determine if they may be at |

|risk for prostate cancer. Prostate cancer can often be genetically impactful. Genetic studies suggest that strong familial |

|History may be responsible for 5% to 10% of all prostate cancers (Huether, pg. 833). |

( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]

|Name amlodipine (Norvasc) |Concentration |Dosage Amount 10mg (1 tablet) |

|Route Oral |Frequency Daily |

|Pharmaceutical class Calcium channel blockers |Home Hospital or Both |

|Indication Management of hypertension |

|Side effects/Nursing considerations Dizziness, fatigue, peripheral edema, angina, hypotension, nausea, flushing; monitor for use with other antihypertensives. |

| |

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

|Route Oral |Frequency Two times daily |

|Pharmaceutical class Stool softeners; laxatives |Home Hospital or Both |

|Indication Prevention of constipation after surgery. |

|Side effects/Nursing considerations Throat irritation, mild cramps, diarrhea, rashes. Excessive or prolonged use may lead to dependence. |

| |

|Name glipizide (Glucotrol) |Concentration |Dosage Amount 10mg (1 tablet) |

|Route Oral |Frequency Two times daily before meals |

|Pharmaceutical class Sulfonylureas |Home Hospital or Both |

|Indication Controls blood sugar in type 2 diabetes mellitus |

|Side effects/Nursing considerations Photosensitivity, hypoglycemia, dizziness, drowsiness, constipation, diarrhea, hyponatremia, aplastic anemia, agranulocytosis, |

|leukopenia, thrombocytopenia; monitor with alcohol consumption and warfarin intake. |

| | | |

|Name Hydromorphone (Dilaudid) |Concentration 10mg/50mL |Dosage Amount PCA dose 0.2mg/1mL |

|Route Intravenous |Frequency Continuous |

|Pharmaceutical class Opioid agonists |Home Hospital or Both |

|Indication Decrease in severity of moderate pain from prostatectomy. |

|Side effects/Nursing considerations Confusion, sedation, hypotension, constipation; monitor for use with other partial antagonist opioids. |

| |

|Name metformin (Glucophage) |Concentration |Dosage Amount 850mg |

|Route Oral |Frequency 2 times daily with meals |

|Pharmaceutical class Biguanides; antidiabetics |Home Hospital or Both |

|Indication Management of type 2 diabetes mellitus |

|Side effects/Nursing considerations Abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic taste, hypoglycemia, lactic acidosis, decreased vitamin B12|

|levels; monitor with alcohol consumption. |

| |

|Name olmesartan (Benicar) |Concentration |Dosage Amount 20mg |

|Route Oral |Frequency Daily |

|Pharmaceutical class Angiotensin II receptor antagonists; |Home Hospital or Both |

|antihypertensives | |

|Indication Hypertension management |

|Side effects/Nursing considerations Dizziness, hypotension, hyperkalemia, sprue-like enteropathy, impaired renal function, angioedema; monitor or use with NSAIDS. |

| |

|Name Insulin aspart (Novolog) lnPn 2-10 units |Concentration |Dosage Amount |

| | |Blood sugar150-199: 2 units |

| | |Blood sugar 200-249: 4 units |

| | |Blood sugar 250-299: 6 units |

| | |Blood sugar 300-349: 8 units |

| | |Blood sugar 350-399: 10 units |

| | | |

| | |Onset: within 15 minutes; peak: 1-2 hours; |

| | |duration: 3-4 hours |

|Route Subcutaneous |Frequency 3 times daily with food and at bedtime |

|Pharmaceutical class Pancreatics |Home Hospital or Both |

|Indication Control of hyperglycemia from type 2 diabetes mellitus |

|Side effects/Nursing considerations Hypoglycemia, anaphylaxis; monitor blood sugar with accuchecks |

| |

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

|Diet ordered in hospital? NPO |Analysis of home diet (Compare to “My Plate” and |

|Diet patient follows at home? Patient reports not following any specific diet at |Consider co-morbidities and cultural considerations): |

|home. | |

|24 HR average home diet: |In relation to “My Plate,” the patient has a relatively |

|Breakfast: Waffles/ Pancakes/ Four slices of French toast/ Grits (10 oz. packet)/|unhealthy diet that does not envelop each portion of the food pyramid. His diet |

|2 eggs/ 4 slices of bacon/ 4 Sausage |contains insufficient amounts of |

|links. |fruits and vegetables, insufficient amounts of dairy and |

|Lunch: Sandwiches: Ham (2 oz.), Cheese (2 oz.), Lettuce, |Grains, and insufficient amount of lean-meat proteins. The |

|Tomatoes, Pickles/ Chicken noodle soup (14.5 oz.), Chips (2 cups) |patient’s diet is extremely high in fat and fatty-proteins, and starch. According|

| |to “My Plate,” the patient should be |

|Dinner: Black eyed peas/ Fried Chicken/ Mashed Potatoes |increasing his intake of fruits, vegetables, and grains. Due |

|(3 cups)/ Corn Bread/ Pork Ribs (Whole rack)/ Beef Tacos (3-4)/ Chinese Fried |to the patient’s increasingly high amounts of fat in his diet, he is at a higher |

|Rice (4 cups)/ Pizza (4-5 slices) |risk of heart problems. Since the patient is |

|Snacks: Popcorn (3 cups)/ Cheese-Itz (2 cups)/ Chips (2 |diabetic, he should be recommended to consume a diet low |

|cups) |in sugar, carbohydrates, and fat. He should also be |

|Liquids (include alcohol): Water/ Sprite/ Grape soda/ Fruit |recommended to limit his use of alcohol and consume less |

|punch/ Beer/ Scotch liquor (16oz.-32oz.) |amounts of salt. Patient is presently consuming an unhealthy diet in reference to|

| |“My Plate.” |

|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as a reference.|

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? |

|Patient states that his wife is his main support system when he is ill. |

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

|Patient states that he is fairly good at coping with stress. He states that when he is upset, he will “grab a six pack of beer |

|and sit on my back porch.” He doesn’t generally talk to anyone when he is upset. He explains that he likes to deal with |

|his problems alone. |

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

|Patient expresses having feelings of depression at the time of his cancer diagnosis. Patient reports feeling anxious for his |

|surgery, but presently feels relieved (post-op.). |

| |

| |

|+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, never |

| |

|Have you ever been talked down to? No Have you ever been hit punched or slapped?  No |

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| |

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|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?  None |

|Are you currently in a safe relationship? |

|Yes. |

| |

|( 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: The stage Ego Integrity vs. Despair is the point in a person’s life where they have become senior citizens, and reflect on their life that |

|they have lived. Ego Integrity is a stage of looking back at your life with positivity and satisfaction, believing that you lead a successful life. On the other |

|hand, Despair is a stage of looking back at your life with negativity, regret, and dissatisfaction. This often leaves a person at a state of depression and |

|hopelessness. |

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

|Patient is in the stage of Ego Integrity vs. Despair, while showing signs of Ego Integrity. Upon interaction with the |

|patient, he showed signs of cheerfulness, and willingness to share stories about his life. The patient is retired, and |

|speaks in a positive fashion about past instances in his life working at the hospital on the kitchen staff. He |

|expressed that he missed working at his job, and “wouldn’t have changed anything.” Patient shows interest in |

|traveling around the world since retiring, and continuing to “live life to it’s fullest.” |

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

|His hospitalization and surgery has given him some anxiety, and his cancer diagnosis had made him depressed, but |

|he is presently relieved and positive. He is moving forward from this surgery and continuing to live his life with |

|the same attitude he was prior to his hospitalization. |

| |

|+3 CULTURAL ASSESSMENT: |

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

|Patient states that he feels that his race has influenced the cause of his illness. He believes that Black men are put |

|at a disadvantage for developing prostate cancer. |

| |

|What does your illness mean to you? |

|Patient states that this illness has made him want to take better care of himself. Patient explains “I am going to tell |

|my brother to get tested for cancer, and get blood work done.” Patient states “I never knew what I had, until I |

|was tested.” |

| |

|+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 (Wife has not). |

|Have you or your partner received the Gardasil (HPV) vaccination? Yes (Wife has received Gardasil) |

|Are you currently sexually active? Yes When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended |

|pregnancy?  Rare usage of condom prior to wife’s menopause. |

| |

|How long have you been with your current partner? 38 years |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity? No. Healing from prostatectomy. |

| |

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

|No, none |

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

What importance does religion or spirituality have in your life?

Patient explains that he is, and has not ever been religious.

Do your religious beliefs influence your current condition?

No. (Patient has no religious beliefs)

|+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? X years |

|Cigarettes |1 pack per day |(age 22 thru 52 ) |

| | |Ongoing |

|Pack Years: 30 pack years | |If applicable, when did the patient quit? |

| | |Never |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? NO|Has the patient ever tried to quit? |

|Patient has not quit smoking. (Still presently smoking 1 pack per day.) |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? (give specific volume) |For how many years? |

|Beer |16oz.-32oz. |(age 21 thru 52 ) |

| | |Ongoing |

| If applicable, when did the patient quit? | | |

|Never. Patient has not quit drinking alcohol. |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

|None |How much? |For how many years? |

| |None |(age thru ) |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

| |None | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|NO |

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|General Constitution: Patient states that he has neither gained nor lost any weight recently. |

|Integumentary: Patient denies any changes in appearance of his skin. Patient denies having problems with his nails, having dandruff, or psoriasis. Patient denies |

|having any hives or rashes, or any skin infections. Patient states that he does not wear sunscreen upon sunbathing. Patient reports normal bathing every day. |

|HEENT: Patient has difficulty seeing. He is farsighted (+1.00), and currently has been wearing glasses to correct his vision since 2002. Patient denies having |

|cataracts or glaucoma. Patient denies having any ear infections or difficulty hearing. Patient also denies having sinus pain, sinus infections, nose bleeds, |

|post-nasal drip, or any oral/pharyngeal infections. Patient reports having surgical removal of his wisdom teeth, along with multiple root canals of some of his |

|molar and incisor teeth. Patient’s pulled teeth are presently absent. Patient reports routinely brushing his teeth twice daily. Gets routine dentist visits every |

|two years. Patient reports getting his vision screened every 6 months. |

|Pulmonary: Patient denies having difficulties breathing, or having dry or productive coughs. Patient also denies having asthma, bronchitis, emphysema, and |

|pneumonia. Patient reports having been exposed to tuberculosis (positive PPD test), but never having active tuberculosis. Patient denies having any environmental |

|allergies. He states that his last chest x-ray was in May of 2014. |

|Cardiovascular: Patient has hypertension. He states that the onset of hypertension has been since 2004. Patient denies having hyperlipidemia, chest pain/angina, or |

|any myocardial infarctions. He also denies have CAD/PVD, CHF, heart murmurs, or thrombi. Patient denies having rheumatic fever, myocarditis, or arrhythmias. He |

|reports that his last EKG screening prior to his prostatectomy on 06/19/14. |

|GI: Patient denies having nausea, vomiting, diarrhea, constipation, or GERD. He also denies having indigestion, hemorrhoids, yellow jaundice, pancreatitis, colitis,|

|or diverticulitis. Patient reports having appendicitis associated with an appendectomy in 1994. Patient denies having any abdominal abscesses, irritable bowel, |

|cholecystitis, gastritis/ulcers, or presence of blood in the stool. He reports of having the Hepatitis B antibody. Patient’s last colonoscopy was 12/09/13. |

|GU: Patient denies having any difficulties urinating, nocturia, dysuria, hematuria, or polyuria. Patient reports having one kidney stone in 2009. He experiences |

|frequent and normal urination 4-5 times a day. Patient denies having any bladder or kidney infections. |

|Men Only: In March of 2014, patient had an infection on the prostate gland associated with Gleason 6 prostate cancer. Patient reports getting a prostate exam every |

|2 years. His last prostate exam was 03/07/14. Patient denies having BPH or urinary retention. |

|Musculoskeletal: Patient reports having a fractured left leg as a child (date unknown). Patient denies any musculoskeletal pain or weakness. He denies having gout, |

|osteomyelitis, or arthritis. Patient reports having frequent lower back pain that started in 2011. |

|Immunologic: Patient denies having any chills with severe shaking, night sweats, fever, HIV or AIDS. He also denies having lupus, rheumatoid arthritis, or |

|sarcoidosis. Patient reports having had a life threatening allergic reaction to metronidazole associated with severe itching, swelling, and burning of the skin. He |

|reports having had a tumor of a Gleason 6 prostate cancer score. Patient denies any enlarged lymph nodes. |

|Hematologic/Oncologic: Patient denies having anemia or receiving any blood transfusions. He explains that he does not bleed easily or bruise easily. Patient’s blood|

|type is O+. |

|Metabolic/Endocrine: Patient reports of having type 2 diabetes mellitus since 2011. He denies any hypothyroid/hyperthyroid issues. Patient also denies having any |

|intolerance to hot or cold, or osteoporosis. |

|Central Nervous System: Patient denies having any central nervous system issues including CVA, dizziness, severe headaches, migraines, seizures, ticks/tremors, |

|encephalitis, and meningitis. |

|Mental Illness: Patient reports of having anxiety prior to his surgery. Patient presently denies any anxiety. He also denies depression, schizophrenia, and bipolar |

|issues. |

|Childhood Diseases: Patient reports of having measles, mumps, and chicken pox as a child. No other childhood diseases, including polio or scarlet fever were |

|reported. |

( 10 Review of Systems Narrative

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

|Patient has not mentioned or sought any other medical attention for anything else besides what is mentioned above. |

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

|Patient expresses that she has no other questions or concerns. |

|±10 PHYSICAL EXAMINATION: |

|General survey: Height 5’7” Weight 205lbs BMI 32.24 Pain (include rating and location) 1/10 in lower abdomen Pulse 69 |

|Blood Pressure (include location) 114/70 (left arm) Temperature (route taken) 97.8 F (oral) |

|Respirations 17 SpO2 94% Room Air or O2 Room Air |

|Overall Appearance Patient is clean with hair combed, and he is dressed appropriately for the setting and temperature. Patient is alert and able to maintain eye |

|contact. He has no obvious handicaps. |

|Overall Behavior Patient is appropriate, awake, calm, and relaxed. He interacted well with me and his judgment appeared to be appropriate and intact. |

|Speech Patient speaks with clear, crisp, diction. |

|Mood and Affect Patient was cooperative, pleasant, and talkative upon interaction. Appeared to be in a positive and humorous mood throughout my shift (0645-1430). |

|Integumentary Patient’s skin is warm, dry, and intact. Skin turgor is elastic. Patient has no rashes, lesions, or deformities of/on the skin. No clubbing of the |

|nails and capillary refill is less than 3 seconds. Patient’s hair is evenly distributed, clean, and without vermin. |

|IV Access Patient has one IV site, located peripherally in his left arm. IV was inserted on 06/19/14. No redness, edema, or discharge present at IV site. Presently |

|infusing intravenous drugs. |

|HEENT Facial features are symmetric, no pain in sinus region, and no pain or clicking of TMJ. Patient’s trachea is midline, thyroid is not enlarged, and lymph nodes |

|are non-palpable. Sclera is white, conjunctiva is clear and without discharge. Patient’s eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands are |

|symmetric without edema or tenderness. Pupils are equal, round, and reactive to light with accommodation (PERRLA). Pupil size is 3mm. Patient’s peripheral vision is |

|intact, and his extra ocular movements (EOM) are intact through 6 cardinal fields without nystagmus. Ears are symmetric with no lesions or discharge. Whisper test |

|heard in both right and left ears at approximately 15 inches distance. Patient’s nose is without lesions or discharge. Lips, buccal mucosa, floor of mouth are |

|without lesions, and tongue is pink and moist without lesions. Both of the patient’s lower central incisors are pulled and absent. |

|Pulmonary/Thorax Patient’s respirations are regular and unlabored. His transverse to AP thorax ratio is 2:1. Chest expansion is symmetric. Lungs are clear to |

|auscultation in all fields without adventitious sounds. Percussion is resonant throughout all lung fields, dull towards posterior bases. Patient produced no sputum. |

|Cardiovascular Patient’s chest has no lifts, heaves, or thrills. PMI felt at 5th intercostal space on the midclavicular line. S1 and S2 heart sounds heard with a |

|regular rate and rhythm. No murmurs, clicks, or adventitious heart sounds heard. No present JVD. Calf pain is bilaterally negative. Pulses, including apical, |

|carotid, brachial, radial, femoral, popliteal, DP, and PT are all equal, bilateral, and 3+ (normal on the rating scale). No carotid or temporal bruits. No present |

|edema, and extremities are warm with capillary refill less than 3 seconds. |

|GI Bowel sounds are normoactive in all 4 quadrants; no bruits auscultated. No organomegaly present. Percussion is dull over the liver and spleen, and tympanic over |

|the stomach and intestines. The abdomen is non-tender to palpation. Patient’s CVA punch is without rebound tenderness. His last bowel movement was 06/18/14 with a |

|semi-formed state and medium brown coloration. A hemoccult was not done for the patient. |

|GU Patient’s urine is clear with a light-orange coloration. Patient’s previous 24 hours output was not documented. He is presently attached to a Foley catheter, and |

|has bathroom privileges with assistance. Patient’s genitalia is clean, moist, and without discharge, lesions, or odors. |

|Musculoskeletal Patient has full range of motion in all extremities without crepitus. Strength is 5/5 equal and bilateral at RUE, LUE, RLE, and LLE. Patient’s |

|vertebral column is without kyphosis or scoliosis. His neurovascular status is intact; his peripheral pulses are palpable, with no pain, pallor, paralysis or |

|paresthesia. |

|Neurological Patient is awake, alert, and oriented to person, place, time, and date. Patient’s cranial nerves 2-12 are grossly intact. His sensation is intact to |

|touch, pain, and vibration. Patient’s gait is smooth and regular with symmetric length of the stride. |

| |

|±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): |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|Prostatic Specific Antigen (PSA) |

|Reference range: 0-4.000 NG/ML |

|Value: 4.576 (HIGH) |

|Blood specimen abnormal |

| |

| |

| |

| |

|(03/05/14) |

|No trend available on chart. This was the only PSA value taken for the patient. |

|The PSA is a protein produced by the prostate gland. Patient shows high level of PSA 3 months prior to hospitalization. An elevated PSA level is associated with men |

|developing prostate cancer. High PSA levels are also known to determine benign conditions such as benign prostatic hyperplasia (BPH) and prostatitis. In this case, |

|the patient’s high PSA level was associated with a Gleason 6 prostate cancer diagnosis followed by a prostatectomy on 06/19/14. |

| |

|CBC |

|WBC |

|Normal (4.6-10.2 k/ul) |

|Value: 6.5 |

|RBC |

|Normal (4.69-6.13 m/ul) |

|Value: 4.57 (LOW) |

|Hemoglobin |

|Normal (14.1-18.1 g/dl) |

|Value: 14.3 |

|Hematocrit |

|Normal (43.5-53.7%) |

|Value: 42.5% (LOW) |

|Platelet Count |

|Normal (142.0-424.0k/ul) |

|Value: 222 |

| |

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|(06/12/14) |

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|(06/12/14) |

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|(06/12/14) |

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|(06/12/14) |

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|(06/12/14) |

|Patient’s file provided no trends for the CDC count due to the fact that only the pre-op levels were documented. Throughout my shift (0645-1430), the patient’s |

|post-op CBC levels were not recorded, therefore a trend cannot be determined. |

|Patient has normal WBC count, but has a low RBC count. Normal WBC indicates that the patient has no present infection or any inflammation. A lowered RBC count, |

|however, may be indicative of nutrition deficiency or anemia. Certain cancers can also decrease a person’s RBC, which may be a causative factor in this patient’s low|

|RBCs. The patient has normal hemoglobin, but presents with a low hematocrit level. Normal hemoglobin resembles a sufficient amount of oxygen perfusing to tissues |

|through the RBCs. A low hematocrit, on the other hand is related to the patient’s low RBC count, associated with his prostate cancer, resembling a lower than normal |

|percentage of RBCs. The patient’s platelet count is within normal range indicating that he has sufficient blood clotting factors. Prior to surgery, it is essential |

|to test a patient’s platelet count to ensure that he will not over-clot, or have insufficient clotting factors, which could lead to extreme blood loss. |

| |

|Metabolic Panel |

|Sodium |

|Normal (135-148 meq/L) |

|Value: 140 |

|Potassium |

|Normal (3.5-5.3 mmol/L) |

|Value: 3.8 |

|Chloride |

|Normal (98-107 meq/L) |

|Value: 105 |

|BUN |

|Normal (6.0-20 mg/dl) |

|Value: 16 |

|Creatinine |

|Normal (0.72-1.25) |

|Value: 1.1 |

|Glucose |

|Normal (70-110 mg/dl) |

|Value: 154 (HIGH) |

| |

| |

| |

| |

|(06/12/14) |

| |

| |

|(06/12/14) |

| |

| |

|(06/12/14) |

| |

| |

|(06/12/14) |

| |

| |

|(06/12/14) |

| |

| |

|(06/12/14) |

|No trend was available for the patient’s metabolic panel because only the pre-op results were documented. The post-op results were not available so no trend could be|

|determined. |

|The patient has normal levels of sodium, potassium, chloride, and BUN/creatinine indicating healthy blood work with no identifiable insufficiencies. However, the |

|patient’s glucose level was extraordinarily higher than normal limits, which is common among diabetic patients. Glucose testing is a measurement of the blood sugar |

|level. Hyperglycemia can be a serious issue if gone untreated. Ketoacidosis is a condition that can develop with extended insulin insufficiencies. Without insulin |

|replacement, a patient can undergo serious life-threatening conditions. In this case the patient receives insulin 3 times a day to maintain his blood sugar. |

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| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

|Patient is currently on an NPO diet due to the fact that he underwent surgery the day before. Patient is |

|awaiting a change in his diet order to be moved from NPO to a liquid diet. He has normal vitals (Blood |

|pressure: 114/70, Respirations: 17, SpO2: 94%, Pulse: 69, Temperature: 97.8 F (oral), and current pain |

|level is 1/10). Patient can currently ambulate around the halls (after getting an order from the physician). |

|No further diagnostic tests or consults were scheduled or were on file. The patient is scheduled to receive |

|accuchecks routinely every 4 hours. These accuchecks are monitoring the patient’s blood glucose level to |

|ensure that his type 2 diabetes mellitus is controlled and that his blood sugar is within a sufficient range. |

|He is ordered to receive accuchecks before meals and at bedtime. Patient is currently connected to a |

|Jackson-Pratt suction bulb to remove any fluids that are accumulating in the area around his prostate due |

|to his prostatectomy. |

| |

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

|1. Risk of infection related to invasive prostatectomy surgery and usage of a Foley catheter. |

| |

| |

|2. Risk of deficient fluid volume related to fluid loss and possible bleeding. |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: Risk of infection related to invasive prostatectomy surgery and usage of a Foley catheter.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is |

| | |Provide References |Provided |

|Remain free from an infection after |Continually assess patient’s |Redness, swelling, discharge, and increase |During my shift (0645-1430), the |

|surgery, while hospitalized |laparoscopic sites for cardinal signs |in temperature are the most common symptoms |patient’s laparoscopic sites were |

| |and symptoms of infection, including |of infection in a patient. If a patient |absent of any redness, swelling, or |

| |redness, swelling, or discharge, |starts to show these signs following a |discharge. Patient’s temperature was |

| |throughout entire shift (0645-1430). |procedure, infection is always a |monitored three times during my shift |

| |Continually retrieve the patient’s |possibility. It is essential to obtain the |with no fever implications. His |

| |temperature to ensure that he is not |patient’s temperature frequently throughout |temperature maintained around 97.8 F, |

| |spiking a fever greater than 100.5 F. |his hospitalization to ensure he is not |indicating there were no present signs |

| | |developing a fever. A fever is often the |of infection. |

| | |first sign of an infection, and can cause | |

| | |the patient to become immunocompromised, | |

| | |allowing for that infection to rapidly | |

| | |become worse and possibly life-threatening. | |

| |Continually instruct the patient to use|Incentive spirometry is a mechanism to |Patient was instructed to inhale |

| |the incentive spirometer to keep his |achieve and restore normal pre-operative |through the incentive spirometer twice |

| |lungs healthy, increase oxygenation, |pulmonary function and breathing in patients|during my shift, once at 0800, and once|

| |and prevent any possible nosocomial |who have just received surgery. Incentive |at 1300. In this morning the patient |

| |infections such as pneumonia. |spirometry is one of the best ways to |was inhaling about 1750mL, and in the |

| | |determine is a patient is possible |afternoon the patient was inhaling |

| | |developing a pulmonary infection. This |2000mL. Patient’s inspiration had |

| | |mechanism can ensure a nurse or healthcare |increased throughout my shift, |

| | |provider that the patient is sustaining |indicating that his pre-operative |

| | |maximal inspiration and showing no signs of |pulmonary function was restoring, and |

| | |infection. |the risk of nosocomial infection (such |

| | | |as pneumonia) was decreasing. |

| |Frequently clean the areas around the |Hygienic practice is the most essential |Throughout my shift, the patient’s |

| |laparoscopic sites on the patient’s |element to ensuring that your patient does |laparoscopic sites, and the skin around|

| |abdomen to ensure that they remain |not accumulate any preventable infections of|them were cleansed and patted dry by |

| |intact and free of infection. |illnesses. By frequently cleaning the areas |the nurse and I. We examined for any |

| | |around the patient’s laparoscopic sites, the|noticeable changes in the skin around |

| | |risk of any bacterial invasion is |the sites, and thoroughly wiped all 4 |

| | |significantly decreased. Clean wound sites |surgical sites. Although the patient |

| | |decrease the availability of bacteria to |was free of infection during my shift |

| | |seep into the wound, or affect the |(0645-1430), the goal was only |

| | |surrounding skin contributing to any |partially met due to the discharge date|

| | |possible infections. |being the night following the end of my|

| | | |shift (06/20/14). |

|Maintain patient education so he may be |Educate the patient on the importance |Giving the patient understandable education |Near the end of my shift, the nurse was|

|discharged with comfort and safety. |of hand hygiene to prevent post- |on hygienic practice is essential to prevent|beginning to educate the patient on the|

| |operative infections. * |infections until the patient is completely |importance of hygiene once he is |

| | |healed. Having the knowledge of how hygiene |discharged. The patient showed |

| | |is important in maintaining proper recovery |compliance and understanding to the |

| | |free of infections is crucial so that the |rules and precautions that the nurse |

| | |patient knows which safety measures to take |was instructing. He verified some of |

| | |in order to comfortably heal. |the precautions back to the nurse by |

| | | |repeating what, and why it was |

| | | |important to maintain hygienic practice|

| | | |when dealing with his post-operation |

| | | |period. |

| |Show, and demonstrate to the patient |Patient’s who undergo laparoscopic |The patient was scheduled to receive |

| |how to measure and empty his catheter. |prostatectomies are advised to not have |education on how to manage his catheter|

| |* |their catheter removed until 1 week after |at home for the next few days, closer |

| | |their surgery. This precaution is taken to |to the time of his discharge. The |

| | |ensure that the urethra is intact, being |patient expressed to me that he was |

| | |fully and correctly attached to the bladder.|aware of having to go home with his |

| | |Education is essential because most people |catheter, but during my shift, the |

| | |are not familiar with having to urinate |nurse had not given any instruction. |

| | |through, and empty a Foley catheter by |Although patient education was |

| | |themselves. Demonstration by the nurse will |scheduled, the goal was only partially |

| | |ensure safety and correct usage of the |met due to the fact that his discharge |

| | |actual catheter, and what precautions to |date and time was after the end of my |

| | |take in order to prevent any urine backflow |shift. |

| | |resulting in possible infection. | |

| |

|±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 |

|□Dietary Consult |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|*F/U appointments |

|□Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes * No |

|□Rehab/ HH |

|□Palliative Care |

|Patient will need a follow up appointment to have his catheter removed 7 days after his surgery date. (06/19/14). Patient will be discharged home, and not to a |

|facility. Patient has the supplies that he will need at home, in ordered to be discharged. When the patient is discharged, he will have his wife to help him return to|

|full recovery. There are no reported financial issues. Patient needs to be instructed on home catheter care. |

References

Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2014). Unbound Medicine, Inc. [Software].

Davis’s Laboratory and Diagnostic Tests (Benicar, Colace, Dilaudid, Glucophage, Glucotrol, Norvasc,

Novolog). Nursing Central

Huether, S. (1996) Understanding Pathophisiology. Chapter 32, Pages 829-833. St. Louis, Missouri: Wilson

"Erikson's Psychosocial Development in Psychology 101." Erikson's Psychosocial Development in Psychology

101 at AllPsych Online. Web. 25 June 2014.

"." . Web. 25 June 2014.

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