UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Michelle Bartholet

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

RS

Male

Assignment Date: 10/10/2015

Agency:

Age: 65

Admission Date: 11/09/2015

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code

Primary Language: English

Acute Myeloid Leukemia

Level of Education: Some College

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired Military; Stand-Up Comedian

Number/ages children/siblings: 1 daughter age 38

Served/Veteran: Army
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: At home with wife.

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: White; Non-Hispanic

Religion: Baptist

Type of Insurance: Ultimate MCR (WNR)

1 CHIEF COMPLAINT:
Fatigue and generalized pain

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
65 year old male presents with history of bladder and prostate cancer (s/p radiation/radical cystectomy surgery/Florida
pouch 3/4/03), rheumatoid arthritis, DM type 2, HTN, and HLD that is presenting for second time chemotherapy for
relapsed acute myeloid leukemia (AML) s/p first induction of chemotherapy 9/23/15-10/22/15. Pt previously tolerated
chemotherapy well, and two painful mouth ulcers resolved since last admission. Pt will be readmitted for consolidation
therapy.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
2/15/2003
3/4/2003
9/16/2015
9/17/2015
9/17/2015
9/21/2015
10/5/2015
10/6/2015
10/29/2015

Operation or Illness

Father
Mother
Brother

7
5
9
5
6
9

Stroke
Tumor

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicabl
e)
Colon
Cancer

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Age (in years)

Type 2 Diabetes Mellitus

Cystoscopy and Prostate Removal
Urostomy
Thrombocytopenia
Anemia
Acute Myeloid Leukemia
Sinusitis
Immunodeficiency
Bone Marrow Aspirate and Biopsy

Comments: Include age of onset

Age of onset was unknown for family history.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date Given Unknown)
Adult Tetanus (Date Given Unknown) Is within 10 years? Yes
Influenza (flu) (Given 10/15/2015) Is within 1 years?
Pneumococcal (pneumonia) (Given 10/15/2015) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

NAME of
Causative Agent
Travatan
Niacin
Metformin

Type of Reaction (describe explicitly)

Itching, watery eyes
Airway constriction, flushing
Diarrhea

No Known Allergies
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)
Acute Myeloid Leukemia (AML) is a malignancy of myeloid bone marrow precursors in which poorly differentiated cells
accumulate in the bone marrow and circulation and is characterized by proliferation and accumulation of abnormal
immature myeloid progenitors (blasts) with reduced capacity to differentiate into more cellular elements. These
disruptions in cellular formation within the bone marrow can lead to bone marrow failure and a variety of widespread
symptoms (Nursing Central, 2014). Etiologies are unknown, however some identified risk factors including genetic
predisposition, radiation exposure, immunodeficiency states, chemical and drug exposure, MDS, cigarette smoking, and
some familial disorders including Fanconi anemia, Bloom syndrome, and other anemias and myelodysplastic syndromes
(Nursing Central, 2014). The signs and symptoms are related to anemia, neutropenia, and thrombocytopenia, which
include: malaise, fatigue, fever, bone pain, bleeding, bruising, and recurrent infections. It is typically diagnosed with a
CBC with differential and bone marrow biopsy (Dawn & Renee, 2014). About 60-80% of patients will achieve complete
remission when treated with induction therapy including Cytarabine (Nursing Central, 2014). However, patients over 70
years of age are intolerant of induction therapy (Dawn & Renee, 2014). WBC counts greater than 100,000 are also greatly
related to increased mortality during the first week of therapy (Dawn & Renee, 2014). Typical treatment includes
induction chemotherapy with Cytarabine (Nursing Central, 2014). Other therapies including postremision therapy,
biotherapy with monoclonal antibodies, and bone marrow or stem cell transplantation also exist (Dawn & Renee, 2014).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name
Concentration
Dosage Amount
Dexamethasone (Decadron)
2 drops
2 drops both eyes
Route
Frequency
Ophthalmic
Pharmaceutical class
Home
Hospital
or
Both
Anti-Inflammatories (steroidal)
Indication
Used systemically and locally in a wide variety of chronic diseases including inflammatory, and allergic responses.
Adverse/ Side effects
Depression, euphoria, hypertension, anorexia, nausea, peptic ulceration, acne, decreased wound healing, ecchymoses, hirsutism, petechiae, thromboembolism,
muscle wasting, osteoporosis, hyperglycemia, adrenal supporession, thromboembolism, and cushingoid appearance.
Nursing considerations/ Patient Teaching
Assess for signs of adrenal insufficiency, monitor daily weights and input/output ratios. Monitor serum electrolytes and glucose: may cause hyperglycemia,
especially in patients with Diabetes. Advise patient to take medication as directed and to not stop medication abruptly, this may result in sudden adrenal
insufficiency. Corticosteroids may cause immunosuppression and may mask symptoms of infection. Inform health care provider if symptoms return or worsen.
Name
Concentration
Insulin ASPART (NovoLOG)
100 units/ml
Route
Subqutaneous
Pharmaceutical class
Home
Antidiabetics / Pancreatics
Indication
Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus.

Dosage Amount
Per sliding scale
Frequency
QID
Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects

Hypoglycemia, anaphylaxis
Nursing considerations/ Patient Teaching
Assess for symptoms of hypoglycemia and hyperglycemia. Monitor blood glucose levels frequently and calculate correct unit dosage amount for administration
based on sliding scale for patient. Ensure patient has meal in reach and eats within 15 minutes of administration.
Explain to the patient that this medication controls hyperglycemia, but does not cure diabetes. Instruct patient on proper blood glucose testing. Instruct patient
on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
Name
Concentration
Dosage Amount
Omeprazole (PriLOSEC)
20 mg
20 mg
Route
Frequency
Oral
BID
Pharmaceutical class
Home
Hospital
or
Both
Antiulcer agent
Indication
Maintenance of healing in erosive esophagitis; GERD; healing of duodenal ulcers
Adverse/ Side effects
Pseudomembranous colitis, abdominal pain, diarrhea, flatulence, nausea/vomiting
Nursing considerations/ Patient Teaching
Instruct patient to take medication as directed. Instruct patient to notify health care professional of onset of black, tarry stools, diarrhea, abdominal pain, or
persistent headache. Advise patient not to treat diarrhea without consulting health professional. Advise patient to avoid alcohol, or products containing aspirin
or NSAIDs, and foods that may cause an increase in GI irritation.
Name
Concentration
Dosage Amount
Lisinopril (Prinivil)
40 mg
40 mg
Route
Frequency
Oral
BID
Pharmaceutical class
Home
Hospital
or
Both
Antihypertensive
Indication
Management of hypertension
Adverse/ Side effects
Dizziness, cough, hypotension, angioedema
Nursing considerations/ Patient Teaching
Monitor patient blood pressure and pulse frequently. Instruct patient to take medication as directed. Caution patient to avoid salt substitutes containing
potassium or foods containing high levels of potassium or sodium. Persistent dry cough may occur and may not subside. Instruct patient to notify health care
professional if any signs of allergic reaction occur.
Name
Concentration
Dosage Amount
Cytarabine (DepoCyt)
1.5mg/m2
1.5 mg/m2
Route
Frequency
IV
Q12
Pharmaceutical class
Home
Hospital
or
Both
Antineoplastics
Indication
Used in combination chemotherapeutic regimens for the treatment of leukemias.
Adverse/ Side effects
Nausea, vomiting, pulmonary edema, severe GI ulceration, alopecia, anemia, leukopenia, thrombocytopenia, chemical arachnoiditis, stomatitis.
Nursing considerations/ Patient Teaching
Caution patients to avoid crowds and persons with known infections and to report symptoms of infection. Instruct patient to report unusual bleeding. Instruct
patient to inspect oral mucosa for redness or ulceration, and advise patient to use good oral care and rinse mouth after eating or drinking. Lab tests will need to
be monitored to check for effectiveness or side effects. Patient should be given any upcoming vaccinations.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route
Pharmaceutical class

Frequency
Home

Hospital

or

Both

Indication
Adverse/ Side effects

University of South Florida College of Nursing Revision September 2014

Nursing considerations/ Patient Teaching

Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Adverse/ Side effects
Nursing considerations/ Patient Teaching

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? 2,000 cal CHO diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient consumed an at home diet of 2,185 calories.
The recommended diabetic diet is 1,800 calories. It is also
recommended that patients control their carbohydrate
intake, and this patient was 2 oz over on the daily
recommendation of grains. Therefore, the patient does not
have the best diet control over his diabetes, and as a result
has a problem with high blood sugar. He did consume
enough vegetables, but was under the recommended
amount for fruits and dairy and over on protein
requirements. The diet only consisted of 586 empty
calories, however it contained 4,325 mg of sodium. The
daily recommended intake of sodium is 2300 mg. Increased
sodium can cause high blood pressure, and cause fluid
buildup. This can cause a problem since this patient is
diabetic since it can lead to further vessel damage, and
kidney damage.
Breakfast: Oatmeal with cinnamon and spice, banana, milk,
scrambled eggs with milk and butter.
Lunch: club sandwich (turkey, roast beef, ham, lettuce,
tomato, mayonnaise), chocolate pudding snack pack, Lays
potato chips, water
Dinner: Double cheeseburger (with everything), French
fries, milk
Snacks: none
Liquids (include alcohol): milk, water
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 and my daughter.
How do you generally cope with stress? or What do you do when you are upset?
I try to pray and go to church, my faith helps me deal with everything that goes on in my life or has happened already.

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

University of South Florida College of Nursing Revision September 2014

Recent depression and anxiety. Having to deal with my illness all over again has been difficult

+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:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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 Ericksons developmental stage for your
patients age group:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is currently in the generativity phase of stage 7 of Eriksons psychosocial development theory. Generativity is
the desire and motivation to guide the next generation and is most commonly accomplished through the development of a
promising career and/or relationships. My patient has one daughter and two grandchildren and was very fond of his bond
with his daughter and being a grandfather. He is also has a career as a comedian and feels very blessed to be able to make
people smile for a living and is very connected to his spiritual life. Since the important events of this phase is guiding the
next generation my patient was clearly in this stage as opposed to self absorption and stagnation. (Treas & Wilkinson,
2014)

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

When asked how he felt his disease has impacted his life, he felt that it was out of his control and probably due to genetics
and stress, but was very optimistic about the future. He also spoke very highly of his career. He also said his daughter and
wife are very helpful and that he has a great support system. He is very fond of developing new relationships and creating
new things. He does not feel like his disease has held him back from his family or jobs, or from making his mark on the
world and therefore he is still in the generativity phase of stage 7 (Treas & Wilkinson, 2014).

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I believe it is a cause of both lifelong stress, aging, and genetics. I believe it was out of my control but it is part of my
plan
in life.
What does your illness mean to you?
I am very spiritual in my daily life and although I have struggled with coming to terms with my illness, I believe God has

University of South Florida College of Nursing Revision September 2014

a plan.

+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?__Yes____________________________________ Have you or
your partner received the Gardasil (HPV) vaccination? __No_______________________
Are you currently sexually active? __Yes_____________________ 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?_40 years__________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _No_________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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

What importance does religion or spirituality have in your life?
_Religion is extremely important in my life, other than my family it is the most important thing to me. I regularly go to church and
pray._____________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_Yes I think without my religion, I would be angry for what has happened. I still struggle, but I believe God has a plan for me and he
knows that I will make it through.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much?
For how many years? 45
(age 20 thru 65 )
Beer
Volume: 2 beers
Frequency: 3-4 times a week;
weekend/social drinker although not
since new diagnosis
If applicable, when did the patient quit?
After being recently diagnosed with AML, he has not had anything to drink. He was unsure about his desire to resume
moderate drinking once healthy.
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

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?
No

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 50
Bathing routine: every night
Other:

Be sure to answer the highlighted area

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? 5 years ago
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other: immunodeficiency

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
Other: Hx Bladder/Prostate Cancer

x/day

2 x/day
1 x/year

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam? Removed
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision September 2014

10

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

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

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11

10 PHYSICAL EXAMINATION:
General Survey:

Height 71 in
Pulse 53
Respirations 18
SpO2 99%

Weight 199 lbs

BMI 29.4
Pain: (include rating and
location)
Blood Pressure: (include location)
5/10 (all over-normal)
145/66 (Brachial)
Temperature: (route
Is the patient on Room Air or O2
taken?) 97.7 (Oral)
Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Heplock
Location: Left Forearm
Date inserted: 11/9/2015
Fluids infusing?
no
yes - what?

flat
loud

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- 12 inches & left ear- 12 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL
LUL CL
RML CL
LLL CL
RLL CL

Chest expansion

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

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12

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

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3
Carotid: 3
Brachial: 3
Radial: 3
Femoral: 3
Popliteal: 3
DP: 3
PT: 3
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date 11 / 9 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
GU
Urine output:
Clear
Cloudy
Color: Yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output:
without assistance

or

mLs N/A

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5__ RUE _5__ LUE __5__ RLE & _5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 2

Biceps: 2

Brachioradial: 2

Patellar: 2

Achilles: 2

Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
University of South Florida College of Nursing Revision September 2014

13

abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Bone Marrow Aspirate &
Biopsy

Dates
10/29/2015

RBC Count
3.25

10/22/2015

2.84

11/7/2015

Blood Glucose
>500
412
444
384

11/9/2015
11/10/2015 (0900)
11/10/2015 (1200)
11/10/2015 (1700)

Trend
Biopsy showed
hypercellular marrow
with 8% blasts in
background of maturity
trilineage hematopoiesis,
and mild normochromic
anemia.

Analysis
The bone marrow biopsy
was performed after the
completion of the
patients first induction of
chemotherapy from 9/2310/22. The overall
features of the test were
morphologically
concerning for residual
AML. As a result, the
patient was scheduled to
for a second round of
chemotherapy to begin on
11/9/2015.
Over the course of the
AML, as well as the
month there has been a
treatment for AML, can
slow downward trend in
cause anemia. The bone
RBC numbers.
marrow biopsy revealed
mild normochromic
anemia, which can also be
noticed in these CBC
blood draws. This RBC
count is lower than
normal (3.91-5.11), and
indicates anemia. This is
also a common finding in
AML to have decreased
RBC production.
The blood glucose levels A normal blood glucose
for this patient have been range is 90-110, however
trending high, with a mild this patient is trending
drop between 11/9 and
extremely high. Since this
11/10 and between 1200
patient was diagnosed
and 1700 on 11/10.
with Type 2 Diabetes
Insulin has been regularly Mellitus in 2003, this
administered per sliding
range of blood glucose
scale for this patient.
levels indicate poor
control of the patients
diabetes.

University of South Florida College of Nursing Revision September 2014

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

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on the 2,000 cal CHO diet while admitted in the hospital. Vital signs were all within normal limits,
although blood pressure was elevated for this patient: Temp 97.7, RR 18, HR 53, BP 145/66, SaO2 99%. Patient
reports fatigue and a generalized, constant, pain of 5/10. The patient is currently not taking pain medications, and
has techniques to cope with the chronic pain. The patient receives accu checks AC/HC (before meals and before
bed) and receives insulin per sliding scale requirements. Patient is able to ambulate without assistance and with
no limitations. Patient is currently scheduled for chemotherapy treatment, and is regularly consulted by the
oncology team and pain management. The patient also requests frequent visits from the chaplain services.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Chronic pain r/t tumor progression and related pathophysiology and as evidenced by patient surgical history, patient
health history of cancer, and patient reporting constant pain of 5/10.
2. Risk for Infection as evidenced by inadequate immune system, inadequate secondary defenses, immunosuppression
related to chemotherapy agents and leukemia disease process. 480
3. Anxiety r/t change in health status and unresolved health as evidenced by patient expressing concerns due to change in
health, awareness of physiological symptoms, patient stating feeling new onset anxiety.
4. Risk for Unstable Blood Glucose level as evidenced by dietary intake, lack of adherence to diabetes management,
physical health status, stress, and medication management.
5. Readiness for Enhanced Spiritual Well-Being as evidenced by patient expressing desire to participate in religious
activities, patient involved in prayer, expressing desire for enhanced hope, and expressing desire for enhanced courage.

University of South Florida College of Nursing Revision September 2014

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 15 CARE PLAN
Nursing Diagnosis: Chronic Pain r/t tumor progression and related pathology as evidenced by patient surgical history, patient health history of
cancer, relapse of cancer, and patient reporting constant pain of 5/10.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Client will describe non
Assess the pain intensity level in
In order to determine the future
The patient outlined his past
pharmacological methods that can
the client
effectiveness of the patients
experiences with pain management
be used to achieve the comfort
preferred method of pain control, it as ineffective. In the past, the client
functioning goal
Ask the patient to describe prior
is important to know what pain the had never tried any non
experiences with pain and
patient normally experiences on a
pharmacological techniques and
effectiveness of past pain
daily basis.
expressed that he preferred to try
management interventions
this method due to the side effects
In order to determine and plan an
of his past medications. He stated
*Teach and implement non
effective pain management
that he is normally at a pain of 5/10
pharmacological interventions such treatment for the patient, it is
and is not always bothered and
as relaxation, meditation, and
important to know what the patient would like to be able to function
distraction activities.
has previously tried, and whether
with this level of pain without the
or not these past attempts were
use of drugs.
effective or not effective in
relieving the pain.
The patient was taught about
different non pharmacological
*Teaching the patient non
techniques for pain management
pharmacological techniques for
including relaxation, medication,
pain management will help the
prayer, and other distraction
patient learn to live with their
activities such as music and more.
chronic pain and also prevent
The patient expressed interest in
dependence and tolerance of pain
using these techniques to avoid
medications. These techniques can medication dependence.
also be used when the patient is
unable to take medications, and
will still allow for pain relief.
Report that the pain management
*Explore appropriate resources for *Once a pain management routine
The patient was consulted by the
regimen achieves long term
management of pain on a long-term has been established, consulting
pain management team and set up
comfort functioning goal
basis
with resources that focus on long
future appointments in order to
term control of pain is important. If continue to effectively manage pain
University of South Florida College of Nursing Revision September 2014

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*Question patient about any

disruption in sleep

the patient is not aware of

outpatient resources, the patient
will not be able to follow up and
*Encourage the patient to plan
get additional help in managing
activities around periods of greatest pain and the long term goal of
comfort whenever possible.
reduced/managed pain will not be
met
*Patients might not realize that
trouble sleeping could indicate
mismanagement of pain. Therefore,
by encouraging patients to report
changes in sleeping patterns, a
more effective pain management
routine can be established.

level.
Patient will report if having
difficulty sleeping or staying
asleep.
The patient determined a schedule
of his normal daily routine to
determine when he would be most
comfortable and plans to save some
time for activities to plan during
this time frame that he enjoys.

*By encouraging the patient to plan

activities around their greatest
comfort, they will be most likely
able to participate in more
activities that they enjoy and will
therefore have a better and happier
quality of life. This will also help
with the distraction from pain.

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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
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Risk for Infection as evidenced by inadequate immune system, inadequate secondary defenses, and immunosuppression related
to chemotherapy agents and leukemia disease process.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate
*Teach patient how to thoroughly
By teaching the patient proper hand Patient expressed proper
appropriate hygiene measures
wash hands and perform care of
hygiene and how to care for sites, it knowledge of hygiene and care of
open sites
will reduce the risk that the patient urostomy/Florida pouch and IV
will contract an infection.
site.
Patient will state the signs and
symptoms of infection

Patient will remain free from

symptoms of infection

*Teach patient the signs and

symptoms of infection and ask
patient to repeat. Send patient
home with a handout report.

By teaching the patients the signs

and symptoms of infection and
asking the patient to repeat the
teaching, the nurse will know that
the patient is aware of what was
taught and the patient will also
have proper knowledge to be able
monitor himself for infection and
report to provider.
Perform proper hand hygiene and
By following proper protocol in all
infection control techniques.
situations, the nurse will reduce the
University of South Florida College of Nursing Revision September 2014

The patient was taught and

expressed understand and repeated
the information to monitor for. The
patient also received a handout
with the information printed for
take-home use.

Patient has not contracted an

infection during the stay and
18

risk of infection spread. If the

Follow proper technique for care of patient also understands how to
urostomy/Florida pouch and IV
avoid locations that are high risk, it
site.
will lower the patients risk of
accidentally getting infected.
*Teach patient to avoid crowds or
people with known infections.

understands the proper protocol to

prevent future infections. The
patient also expresses
understanding of their personal
risk. The patient also expressed
understanding of how to avoid
external risks such as crowds and
known infection.

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
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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19

References

Treas, L & Wilkinson, J. (2014). Development: Infancy Through Middle Age. In Basic Nursing: Concepts,
skills, & reasoning (pp. 163-190). Philadelphia, PA: FA. Davis Company.
SuperTracker. (n.d). Retrieved July 13, 2015. https://www.supertracker.usda.gov/
Nursing Central. (n.d.). Retrieved July 13, 2015. http://nursing.unboundmedicine.com/nursingcentral
Dawn, L., & Renee, H. (2014). Caring for the Patient with Cancer. In K. S. Osborn, C. E. Wraa, A. B. Watson,
& R. Holleran (Eds.), Medican-Surgical Nursing Preparations for Practice. (2nd Edition, pp 1564-1565).
Boston, Massachusetts: Pearson Education.

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