UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kimone Wright
Assignment Date: January 23, 2016
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: Florida Hospital of Tampa
1 PATIENT INFORMATION
Patient Initials: H.R. Age: 82 Admission Date: February 22, 2016
Gender: Male Marital Status: Married Primary Medical Diagnosis:
Bladder cancer
Primary Language: English
Level of Education: Bachelors Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Electrical Engineer
Number/ages children/siblings:
2 children ages 40 (daughter) and 44 (son)
1 brother age 78

Served/Veteran: Yes Code Status: Full Resuscitation

If yes: Ever deployed? Yes or No
Living Arrangements: Lives with wife at home Advanced Directives:
Healthcare Directive, Living Will
If no, doDate:
Surgery they want to fill
January 22,them
2016out?
Procedure: Transurethral Resection of the Prostate
Culture/ Ethnicity /Nationality: European
Religion: Lutheran Type of Insurance: Humana PPO

1 CHIEF COMPLAINT:
Transurethral Resection of the Prostate (TURP)/ Bladder tumor

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is an 82-year-old gentleman who was admitted on February 22, 2016 for a resection of bladder tumor. On
April 23, 2015, the patient was brought in for the same problem and had a resection done on that said date. Results
showed low-grade papillary tumor with superficial submucosal involvement. However, in December, the patient had a
cystoscopy which showed the recurrent tumor on the base of his bladder, the bladder neck, and on to the prostatic fossa.
Previous retrograde was done on the left that showed J hooking, but a retrograde was not done on the right side. The
patient has been on warfarin and aspirin, which had been stopped 5 days prior to the surgery.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
University of South Florida College of Nursing Revision September 2014 1
 Date Operation or Illness
02/22/16 Cystoscopy/TUR Bladder Tumor: Resection of the bladder tumor with transurethral resection of the
prostate
02/22/16 Cystoscopy/Retrograde Pyelogram: Resection of the bladder tumor with transurethral resection of the
prostate
04/23/15 Cystoscopy/TUR Bladder Tumor: Bilateral retrograde pyelogram attempted, transurethral bladder
tumor
06/27/13 Thoracoscopy/Thoractomy-Robotics: Robotic Right Upper Lobectomy with Mediastinal Lymph
Node Dissection
05/28/13 Inguinal/Groin Exploration: Evacuation and drainage of right groin seroma
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of
Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
MEDICAL

Gout
Death

Mental
Heart
HISTORY (if

(angina,
applicabl
e)
Father
Mother
Brother
Sister
relationship

relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? 4 years
Influenza (flu) (Date) Is within 1 years? Last year
Pneumococcal (pneumonia) (Date) Is within 5 years? N/A
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 2

 1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
Type of Reaction (describe explicitly)
REACTIONS
None N/A

Medications

None N/A
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Bladder cancer occurs more frequently in older adults over the age of 65. Bladder tumors are four times more
common in men than in women; it is the fourth most common cancer in men, and the ninth most common cause of death
by cancer in men (Osborn, Wraa, Watson, & Holleran, 2014). There are three main categories of tumors: supervision
noninvasive, invasive into underlying muscles, and metastatic, however, approximately 90% of bladder tumors are
transitional cell carcinomas that arise from the transitional epithelium of mucous membranes (Osborn et al., 2014). Bladder
tumors may develop on the surface of the bladder wall or within the wall. There are a number of risk factors that
contribute to primary bladder cancer. The risk is greater among people who smoke (approximately 50% of those
diagnosed with bladder cancer are smokers) or are exposed to metabolites of aniline dyes, beta naphthylamine, and
benzidine (Osborn et al., 2014). However, other risk factors may include artificial sweeteners, nitrates, and exposure to
certain chemotherapeutic agents.

According to Huether and McCance, the first sign of bladder tumor is most commonly gross, painless,
intermittent hematuria, often accompanied by lower urinary tract symptoms, including daytime voiding frequency,
nocturia, urgency, and urge urinary incontinence. Huether and McCance continued to say that flank pain may occur if
tumor growth obstructs one or both ureterovesical junctions. Patients with bladder tumor may also present with signs of
urinary tract infection or an actual infection. Cancer may spread to other sites in the body by metastasis. Metastasis of
bladder cancer is usually to lymph nodes, liver, or lungs. Also, secondary bladder cancer develops by invasion of cancer
from bordering organs, such as cervical carcinomas in women or prostatic carcinoma in men.

There are no screening tool to detect bladder cancer early. However, bladder cancer is detected by cystoscopy,
biopsy, IVP, CT Scan, renal ultrasound, and MRI (Osborn et al., 2014). Treatment of bladder cancer will depend on the
stage and grade of the cancer. According to Osborn, Wraa, Watson, and Holleran, if the cancer has not invaded the muscle,
the tumor can be removed by transurethral resection, intravesicular chemotherapy, in which the bladder is directly washed
with an antineoplastic, and intravesicular immunotherapy, in which the bladder is directly washed with Bacillus Calmette-
Guerin (BCG). Tumors that are too large to be removed transurethrally, are located away from the bladder neck and
urethral orifice, or have not responded to intravesical therapy, may be eligible for a partial cystectomy, although
recurrence is common. Tumors that have infiltrated the muscle require a radical cystectomy (removal of the entire bladder
and lymph nodes). In men, this may also include removal of the prostate, part of the urethra, and the seminal vesicles; in
women, the uterus, cervix, ovaries, fallopian tubes, and part of the vagina may be removed. Advanced bladder cancers
will also require radiation therapy and chemotherapy. These modalities may be used before or after cystectomy. Radiation
may be used as a primary treatment modality in patients who are not able to tolerate chemotherapy or have invading
cancer without lymph node involvement.

University of South Florida College of Nursing Revision September 2014 3

 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: amiodarone (Pacerone) Concentration: N/A Dosage Amount: 200 mg
Route: Oral Frequency: Daily
Pharmaceutical class: Class III antiarrhythmic Home Hospital or Both
Indication: Life-threatening ventricular arrhythmias unresponsive to less toxic agents
Adverse/ Side effects:
Life threatening: Adult Respiratory Destress Syndrome (ARDS), pulmonary fibrosis, pulmonary toxicity,
congestive heart failure, worsening of arrhythmias, QT interval prolongation, toxic epidermal necrolysis
Most frequent: dizziness, malaise, fatigue, corneal microdeposits, bradycardia, hypotension, anorexia,
constipation, nausea, vomiting, photosensitivity, hypothyroidism, ataxia, involuntary movement,
paresthesia, peripheral neuropathy, poor coordination, tremor
Nursing considerations/ Patient Teaching:
1) Grapefruit juice inhibits enzymes in the GI tract that metabolize amiodarone resulting in increased
levels and risk of toxicity; avoid concurrent use.
2) Monitor ECG continuously during IV therapy or initiation of oral therapy. Report bradycardia or
increase in arrhythmias promptly.
3) Assess for signs of pulmonary toxicity (rales/crackles, decreased breath sounds, pleuritic friction
rub and pain, fatigue, dyspnea, cough, wheezing, fever, hemoptysis, hypoxia.
4) Chest x-ray and pulmonary function tests are recommended before therapy.
5) Patients are at risk for falls.
6) Monitor liver and thyroid functions before and every six months during therapy.

Name: amlodipine (Norvasc) Concentration: N/A Dosage Amount: 10 mg

Route: Oral Frequency: Daily
Pharmaceutical class: Calcium channel blockers Home Hospital or Both
Indication: Alone or with other agents in the management of hypertension, angina pectoris, and
vasospastic (Prinzmetals) angina.
Adverse/ Side effects:
Dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival hyperplasia,
nausea, flushing
Nursing considerations/ Patient Teaching:
1) Monitor:
a) BP and pulse before therapy, during dose titration, and periodically during therapy
b) ECG periodically during prolonged therapy
c) Intake and output ratios and daily weight. Assess for signs of heart failure
2) Assess location, duration, intensity, and precipitating factors of patients angina pain.
3) Advice patient to take medication as directed, even if feeling well. Take missed doses as soon as
possible within 12 hours of missed dose. If greater than 12 hours since missed dose, skip dose and
take next dose at scheduled time. Do not double dose.
4) Instruct patient on concurrent nitrate or beta blocker therapy to continue taking both medications
as directed and to use SL nitroglycerin as needed for angina attacks. Patients should contact health
care professional if chest pain does not improve or worsens after therapy.
5) Patience should comply with other intervention for hypertension, which includes, weight reduction,
low sodium diet, smoking cessation, moderation of alcohol consumption, regular exercise, and stress
management.
6) Patients should change positions slowly to minimize orthostatic hypotension.

University of South Florida College of Nursing Revision September 2014 4

Name: aspirin Concentration: N/A Dosage Amount: 81 mg
Route: Oral Frequency: Daily
Pharmaceutical class: Salicylates Home Hospital or Both
Indication:
Inflammatory disorders, mild to moderate pain, fever, prophylaxis of transient ischemic attacks and MI
Adverse/ Side effects:
Life threatening: GI bleeding, anaphylaxis, laryngeal edema
Most frequent: dyspepsia, epigastric distress, nausea, rash
Others: tinnitus, abdominal pain, anemia, hepatotoxicity, vomiting, hemolysis, urticaria
Nursing considerations/ Patient Teaching:
1) Patients should take aspirin with a full glass of water and remain in an upright position for 15-30
minutes after administration.
2) Patients should report tinnitus, unusual bleeding of gums, bruising, black tarry stools, or fever
lasting longer than 3 days.
3) Patients who have asthma, allergies, and nasal polyps or who are allergic to tartrazine are at an
increased risk of developing hypersensitivity reactions.
4) Patients should avoid concurrent use of alcohol with aspirin to minimize possible gastric irritation.
5) Patients on a sodium-restricted diet should avoid effervescent tablets or buffered-aspirin
preparations.
6) Patients on long-term therapy should inform health care professional of medication regimen before
surgery. Aspirin may need to be withheld for one week before surgery.
7) Tablets with acetic (vinegar-like) odor should be discarded.

Name: benazepril Concentration: N/A Dosage Amount: 40 mg

Route: Oral Frequency: Daily
Pharmaceutical class: ACE Inhibitor Home Hospital or Both
Indication: Alone or with other agents in the management of hypertension.
Adverse/ Side effects:
Life threatening: Angioedema
Most frequent: Dizziness, cough, hypotension,
Others: Drowsiness, fatigue, headache, nausea, impaired renal function, rash, hyperkalemia
Nursing considerations/ Patient Teaching:
1) Angioedema may occur at any time during therapy. Hence, patients should be assessed for
angioedema and if present, medication should be discontinued and supportive care should be
provided.
2) Monitor BP and pulse frequently during initial dose adjustment and periodically during therapy.
3) Patients should take medication as directed at the same time each day even if feeling well. Take
missed dose as soon as remembered but not if almost time for next dose.
4) Patients should comply with additional interventions for hypertension, for example, weight loss.
5) Patients should change positions slowly to minimize hypotension.
6) Patients should notify healthcare professional if rash, mouth sores, sore throat, fever, swelling of
hands or feet, irregular heartbeat, chest pain, dry cough, hoarseness, swelling of face, eyes, lips or
tongue, or if difficulty swallowing or breathing occurs.
7) Diabetic patients should monitor blood glucose closely.
8) Follow-up examinations are very important, especially during the first month of therapy.

Name: finasteride Concentration: N/A Dosage Amount: 5 mg

University of South Florida College of Nursing Revision September 2014 5

Route: Oral Frequency: Daily
Pharmaceutical class: Androgen inhibitors Home Hospital or Both
Indication: Benign prostatic hyperplasia (BPH), Androgenic alopecia in men only
Adverse/ Side effects:
Life threatening: prostate cancer (high grade), angioedema, breast cancer
Others: gynecomastia, decreases the volume of ejaculate, erectile dysfunction, infertility
Nursing considerations/ Patient Teaching:
1) Digital rectal examinations should be before and periodically during therapy.
2) Patients should take finasteride as directed, even if symptoms improve or are unchanged.
3) Patients should notify healthcare professional promptly if changes in the breasts (lump, pain, nipple
discharge) occur.
4) Patients should be informed that there is an increased risk of high grade prostate cancer in men
taking this drug.
5) Periodic follow-up exams are very important to determine whether a clinical response has occurred.

Name: omeprazole Concentration: N/A Dosage Amount: 20 mg

Route: Oral Frequency: Daily
Pharmaceutical class: Proton pump inhibitor Home Hospital or Both
Indication:
PO and IV: GERD/erosive esophagitis
IV: Reduction in risk of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal
ulcers.
PO: 1) Hypersecretory conditions, including Zollinger-Ellison syndrome.
2) With amoxicillin and clarithromycin to eradicate Helicobacter pylori in duodenal ulcer disease.
3) Decrease the risk of gastric ulcer during continuous NSAID therapy.
OTC: Heartburn occurring more than or equal to twice per week.
Adverse/ Side effects:
Life threatening: Clostridium Difficile-Associated diarrhea (CDAD)
Others: Abdominal pain, constipation, diarrhea, dry mouth, flatulence, nausea, hypomagnesemia, acute
interstitial nephritis, vitamin B12 deficiency, bone fracture
Nursing considerations/ Patient Teaching:
1) Monitor bowel function.
2) May alter hemoglobin, WBC, platelets, serum sodium, potassium, and thyroxine levels.
3) Patients should take medication as directed at the same time each day even if feeling well. Take
missed dose as soon as remembered but not if almost time for next dose.
4) Patients should avoid alcohol. Products containing aspirin or NSAIDS, and foods that may cause an
increase in GI irritation.
5) Patients should report onset of black, tarry stools, diarrhea, abdominal pain or persistent headache
to healthcare professional promptly.
6) Patients should notify healthcare professional if fever and diarrhea occur, especially if stool contains
blood, pus, or mucus.
7) Patients should notify healthcare professional if hypomagnesemia (seizures, dizziness, abnormal or
fast heartbeat, jitteriness, jerking movements or shaking, muscle weakness, spasms of the hands
and feet, cramps or muscle aches, spasm of the voice box) occur.

Name: simvastatin Concentration: N/A Dosage Amount: 20 mg

Route: Oral Frequency: Daily
Pharmaceutical class: Hmg Coa Reductase Inhibitor (Statin) Home Hospital or Both

University of South Florida College of Nursing Revision September 2014 6

Indication:
Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.
Secondary prevention of myocardial infarction, coronary revascularization, stroke, and cardiovascular
mortality in patients with clinically evidence coronary heart disease.
Adverse/ Side effects:
Life threatening: Rhabdomyolysis
Most frequent: Abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes
Others: amnesia, confusion, dizziness, headache, insomnia, memory loss, weakness, altered taste, drug-
induced hepatitis, dyspepsia, increased liver enzymes, nausea, pancreatitis, erectile dysfunction, pruritus,
hyperglycemia, arthralgia, immune-mediated necrotizing myopathy, hypersensitivity reactions.
Nursing considerations/ Patient Teaching:
1) If patient develops muscle tenderness during therapy, CPK levels should be monitored.
2) Patient should take medication as directed. They should not skip doses nor double up on missed
doses.
3) Patients should instruct healthcare professional if unexplained muscle pain, tenderness, or
weakness occurs, especially if accompanied by fever or malaise.
4) Patients should wear sunscreen and protective clothing to prevent photosensitivity reactions.
5) Patients should notify healthcare professional of medication regimen before treatment or surgery.

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 7

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? No Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Consider co-morbidities and cultural considerations):
Yes
24 HR average home diet:
Breakfast: cooked cereal such
as oatmeal and Farina (wheat
cereal), eggs, beacon, grits

Lunch: grilled steak or meat

balls, salad, potatoes, pasta,
ready to go pirogues

Dinner: cheese and crackers,

popcorn

Snacks: raw almonds

Liquids (include alcohol):

coffee (black), water, alcohol-
martini

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.

A balanced diet consists of an appropriate amount of grains, vegetables,

fruits, dairy, protein, and water. According to ChooseMyPlate.gov, the
recommended amounts of grains, vegetables, fruits, dairy, and protein that
should be consumed on a daily basis are 6 oz., 2.5 cups, 2 cups, 3 cups, and 5.5
oz. respectively (United States Department of Agriculture, 2015). However, the
patients average daily consumption is 5 oz. of grains (under), 1.75 cups of
vegetables (under), 0 cup of fruits, 0.75 cups of dairy products (under), and 12
oz. of protein (over). On an average, the patient consumes 1,891 calories on a
daily basis. The total amount of calories recommended daily is 2,000 calories.
Also, the patient consumes 25 grams (over) of saturated fat when the limit is 22
grams. He also consumes an average of 2,657 mg (over) of sodium on a daily
basis, when the recommended amount is 2300 mg.
These results clearly show that the patient does not have a balanced diet
and some modifications need to be made to his diet. For example, the patient
does not include fruits in his average 24-hour home diet but he eats an excessive
amount of protein and animal fats. Studies have found high rates of many
cancers in countries where consumption of animal fat is high. Also, people
whose diets are low in fruits and vegetables experience twice the risk of cancer
than those with high intake (Bladder Cancer WebCafe, 2009). The patient also
drinks Martini nightly. Diet and cancer studies have shown that, in general,
vegetables and fruits (citrus, carrots, green leafy vegetables, and cruciferous
vegetables), soy products, whole grain wheat products, and certain nutrients
seem to be protective against cancer, whereas fat, excessive calories, and
alcohol are linked to increased risk (Bladder Cancer WebCafe. (2009). The
beneficial effect of vegetables, fruits, and whole grains may be due to either
University of South Florida College of Nursing Revision September 2014 8
 individual or combined effects of their constituents, including fiber, micro
nutrients, and phytochemicals.
The patient definitely needs to include fruits and vegetables in his diet
on a daily basis, and less protein and fatty foods. Consuming substantial
quantities of fruits and vegetables generally replaces eating large amounts of
animal fats. He also needs to reduce his sodium intake. High sodium intake
may negatively affect his hypertension. Overall, I would recommend that the
patient eats vegetables, fruits, dairy, grains, protein, and drinks water in the
correct proportion. I would also recommend that the patient do more physical
exercise with his dietary changes. According to ChooseMyPlate.gov, the
physical activity target for this patient is 150 minutes per week.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Patients wife, daughter, and son help him when he is ill.

How do you generally cope with stress? or What do you do when you are upset?
Patient states that he rarely gets upset. He also said, thats hard to say. I may go to study or do paperwork. However, most
times we work it out.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
Patient stated that he has no recent difficulties.

+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?

Patient has never felt unsafe in a close relationship

Have you ever been talked down to?

Patient responded by saying, yeah! Oh sure!

Have you ever been hit punched or slapped? Patient stated that he had been hit before.

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Patient stated that he has never been emotionally or physically harmed in other ways by a person in a close relationship
with him.
If yes, have you sought help for this? N/A

Are you currently in a safe relationship?

Patient said that he is currently in a safe relationship.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.

University of South Florida College of Nursing Revision September 2014 9

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 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:
Erikson believes that ego integrity reflects a satisfaction with life and an understanding of ones place in the
life cycle, while, a sense of loss, discomfort with life and aging, and a fair of death are seen in despair (Treas
and Wilkinson, 2014). The task at this stage is the acceptance of ones life, worth, and eventual death. I believe
that this patient is satisfied with his life and accepts his place in the life cycle. He appears to have a healthy
relationship with his wife and children, and is in an acceptable physical state for his age and medical history.
The patient states that he rarely gets upset, and has never been emotionally or physically harmed by a person in
close relationship with him. Also, he stated that he is in a safe relationship with his wife and they have learnt,
over the years, how to compromise and make each other happy.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I do not believe that the Transurethral Resection of the Prostate procedure has a great impact on the patients
developmental stage. However, the patient mentioned that he is sexually active, and with this surgery, he may
not be able to participate into any sexually activities for a few weeks due to sexual dysfunction. This may
temporarily decrease his sense of satisfaction with life and he may feel as though he is not doing his job as a
husband.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient responded by saying, it just happened. I dont know what particularly caused it. I know my past lung and tongue
cancer must have been from smoking, but I dont know what caused the bladder cancer.

What does your illness mean to you?

Patient said that his illness does not mean anything to him.

+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?

Patient is currently sexually active.

Do you prefer women, men or both genders?

Patient prefers women.

Are you aware of ever having a sexually transmitted infection?

Patient said that he is aware of having a sexually transmitted infection in the past.
Have you or a partner ever had an abnormal pap smear?
Patient said that his partner has never had an abnormal pap smear.

Have you or your partner received the Gardasil (HPV) vaccination?

Patient said that neither he nor his partner has received the Gardasil (HPV) vaccination.

University of South Florida College of Nursing Revision September 2014 10

Are you currently sexually active?
Patient is currently sexually active.
If yes, are you in a monogamous relationship?
Patient is in a monogamous relationship

When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy?
When sexually active, patient do not take any precaution to prevent acquiring a sexually transmitted disease or an
unintended pregnancy.

How long have you been with your current partner?

Patient has been with his current partner for 58 years.

Have any medical or surgical conditions changed your ability to have sexual activity?
Patient said that his current medical condition changed his ability to have sexual activity.

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
Patient has no concern about sexual health or how to prevent sexually transmitted disease or unintended pregnancy.

University of South Florida College of Nursing Revision September 2014 11

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
When asked what importance religion or spirituality has in the patients life, the patient replied by saying, pretty important, but not
overly so.

______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
The patients religious beliefs does influence his current condition. Because of his religious beliefs, he feels more confident in
recovering from his illness and surgery.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? 50 years
The patient used to smoke pipes and cigars He smoked two packs per day (age 16 thru 66 )

If applicable, when did the

Pack Years:
patient quit?
He smoked approximately 730 packs per year
The patient had quit at age 66

Has the patient ever tried to quit?

The patient had tried to quit a number of times and was
Does anyone in the patients household smoke tobacco?
successful about 16 years ago
No one in the patients household smokes tobacco
If yes, what did they use to try to quit?
If so, what, and how much? N/A
The patient said that one day he just decided that he had to
quit and he did.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
The patient drinks Martini Volume: an ounce and a half (age 11 thru 82- currently)
Frequency: daily
If applicable, when did the patient quit?
N/A

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
N/A How much? N/A For how many years? N/A
(age thru )

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?
The patient has never been exposed to any occupational or environmental Hazards/Risks.

5. For Veterans: Have you had any kind of service related exposure?
The patient has never had any kind of service related exposure.

University of South Florida College of Nursing Revision September 2014 12

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Yes Diverticulitis Life threatening allergic reaction
Bathing routine: every morning Appendicitis Enlarged lymph nodes
Other: N/A Abdominal Abscess Other: N/A
Be sure to answer the highlighted area Last colonoscopy? N/A
HEENT Other: N/A Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: Not Known
Post-nasal drip Normal frequency of urination: 3x/day Other: N/A
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth: 1x/day
Diabetes Type:
(evenings)
Routine dentist visits: 4x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: N/A Osteoporosis
Other: N/A
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? N/A Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? N/A Encephalitis
last CXR? N/A menopause age? N/A Meningitis
Other: N/A Date of last Mammogram &Result: N/A Other: N/A
Date of DEXA Bone Density & Result:
N/A
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Frequency of prostate exam?
Hyperlipidemia Schizophrenia
Every 5 years
Chest pain / Angina Date of last prostate exam? 02/22/16 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other: N/A
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps

University of South Florida College of Nursing Revision September 2014 13

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

General Constitution
Recent weight loss or gain
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health?
Patient believes that he is in pretty good shape for his age, especially because of his history of smoking.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
There is no problem that is not mentioned that the patient sought medical attention for with anyone.

Any other questions or comments that your patient would like you to know?
The patient said that he really likes to travel and he and his wife travel a lot.

University of South Florida College of Nursing Revision September 2014 14

10 PHYSICAL EXAMINATION:

General Survey: Height: 195 cm Weight: 105 kg BMI: 27.61 Pain: (include rating and
Patient has no obvious Pulse: 60 bpm Blood Pressure: (include location) location)
abnormalities Respirations: 17 br/min 141 mmHg SBP/56mmHg DBP No pain
Temperature: (route SpO2: 96% Is the patient on Room Air or O2?
taken?) 98.4 degrees- 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 flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: N/A Location: N/A Date inserted: N/A
Fluids infusing? no yes - what? N/A

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

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

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

Cardiovascular: No lifts, heaves, or thrills
University of South Florida College of Nursing Revision September 2014 15
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Calf pain bilaterally negative Pulses bilaterally equal: 3 [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 62 Carotid: Brachial: Radial: Femoral: Popliteal: DP: PT:
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: N/A 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 02 /21/16) 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: N/A
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe: Genitalia is clean, moist, without lesions. However, there is little bloody discharge due to removal of
urinary catheter.

GU Urine output: Clear Cloudy Color: Light pink Previous 24 hour output: 4300 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___5____ RUE ____5___ LUE ____5___ RLE & ____5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration 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

University of South Florida College of Nursing Revision September 2014 16

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

Lab Dates Trend Analysis

Retrograde pyelogram February 22, 2016 Resection of the bladder Retrograde pyelogram is
tumor with transurethral a urologic procedure
resection of the prostate where the physician
injects contrast into the
ureter in order to
visualize the ureter and
kidney.

Urinalysis February 23, 2016 RBC: 4.31 (L) Used to diagnose urinary
system and kidney
RBC Count disease. Red blood cells
Normal: 4.6-6.2 and hematuria are
expected abnormalities.

Cystoscopy February 22, 2016 The doctor examines the Main test used to
whole lining of the diagnose bladder cancer.
April 23, 15 bladder and urethra by
gently passing the
cystoscope through the
urethra and into the
bladder.

CT Scan NOT IN CHART Results may display renal Used to detect tissue
lesions and the abnormalities in the
progression of bladder kidney and urinary
cancer. system. Therefore this
should be done on a
patient with bladder
cancer. The results,
however, should be
abnormal.

Ultrasonography NOT IN CHART May detect metastasis Used to identify the size
outside of the bladder. of the kidneys and tissue
abnormalities. Therefore
this should be done on a
patient with bladder
cancer and the results
should be abnormal.

Excretory Urography NOT IN CHART Results may show Done to evaluate the
University of South Florida College of Nursing Revision September 2014 17
 damage to the bladder structure, size, and
Normal: Normal and surrounding function of the kidneys,
structure, size, and structures by a tumor. ureter and bladder.
function of the kidneys, Therefore this should be
ureter and bladder. done on a patient with
bladder cancer. The
results, however, should
be abnormal.

+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.)
1) Transurethral Resection of the Prostate to relieve moderate to severe urinary symptoms caused by an
enlarged prostate.
2) Patient is encouraged to take medications as directed by his healthcare professional and be present for
scheduled tests (for example, cystoscopy) and consults.
3) Patient is encouraged to ambulate as frequently as possible to prevent thrombus formation.
4) Patient is encouraged to practice strict aseptic techniques to prevent infection.
5) Patient is encouraged to increase fluid intake to prevent formation of calculi and infection.
6) Patient is encouraged to follow a balance diet, including moderate amount of lean protein to aid in
healing.

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

1. Impaired urinary elimination related to Transurethral Resection of the Prostate as evidence by patient drinking
large amounts of fluid and took approximately 3 hours to void after the removal of the urinary catheter.

2. Bleeding related to Transurethral Resection of the Prostate as evidence by hematuria.

3. Ineffective self-health management related to deficient knowledge as evidence by patient having unbalanced
nutrition regardless of his history of bladder cancer and hypertension.

4. Risk for acute pain related to reflex muscle spasm associated with Transurethral Resection of the Prostate.

5. Risk for urinary tract infection related to Transurethral Resection of the Prostate.

University of South Florida College of Nursing Revision September 2014 18

 15 CARE PLAN
Patient Goals/Outcomes
Patient will:
Void normal amounts without
retention
Demonstrate behaviors to regain
bladder/urinary control
University of South Florida College of Nursing Revision September 2014
Nursing Diagnosis: Nursing Diagnosis goes here
Nursing Interventions to Achieve Rationale for Interventions
Goal
Encourage patient to keep a
bladder diary/log to record pattern
of urination, amount of voiding,
and size of stream after catheter is
removed.
Perform focused physical
assessment including, percussion
and palpation of the lower
abdomen looking for obvious
bladder distention or an enlarged
kidney.
Assist patient to adopt to normal
position when voiding. Instruct
them to stand and walk to the
bathroom at frequent intervals after
catheter is removed.
*Encourage fluid intake to 3000
mL as tolerated. Limit fluids in the
evening, once catheter is removed.
*Encourage patient to void when
urge is noted but not more than
Provide References
After the removal of the catheter,
voiding may continue to be a
problem for some time because of
urethral edema, blood clots,
bladder spasm, and loss of bladder
tone (Ackley and Ladwig, 2014).
A palpable kidney or bladder
provides direct evidence of dilated
urinary collection system (Ackley
and Ladwig, 2014).
Promotes sense of normality and
encourages passage of urine.
Maintains adequate hydration and
renal perfusion for urinary flow.
Reducing fluid intake at the right
schedule decreases the need to void
and interrupt sleep during the
night.
Voiding with urge prevents urinary
retention. Limiting voids to every 4
Evaluation of Goal on Day Care
is Provided
Patient voided approximately 3
hours after the removal of the
urinary catheter. The urine was
light pink which signifies a small
amount of blood.
Kidney and bladder was not
palpable. Hence, there was no
obvious bladder distention or an
enlarged kidney.
Patient adopted to normal position
when voiding. He stood and
walked to the bathroom twice after
the catheter was removed.
Patient drank moderate amount of
fluid. Approximately 2300 mL.
Patient was able to void when urge
was noted.
19
 every 2 to 4 hours per protocol. hour (if tolerated) increases bladder
tone and aids in bladder retraining
(Ackley and Ladwig, 2014).

*Instruct patient to perform Helps regain control of the bladder, Patient was able to perform
perineal exercises: tightening sphincter, or urinary control and perineal exercises at different
buttocks, stopping and starting minimizes incontinence (Ackley intervals throughout the day.
urine stream. and Ladwig, 2014).

State absence of pain and Question the client regarding Pain management techniques can Patient mentioned having slight
tenderness during urination presence of pain in the area of the be implemented if needed. pain and tenderness during
bladder and possible aggravating urination.
and alleviating factors

Check for costovertebral Costovertebral tenderness is seen No costovertebral tenderness was

tenderness with pyelonephritis and kidney observed.
stones. If present, the necessary
treatments can be implemented
(Ackley and Ladwig, 2014).

Patient will:
Reduce hematuria as soon as Monitor the client closely for Clients at increased risk for Hematuria was noted. However, the
possible. hemorrhage/hematuria. bleeding may include older urine was pink, which suggests that
individuals over the age of 65 bleeding was controlled.
(Ackley and Ladwig, 2014). TURP
is a procedure that causes bleeding.
Bleeding should be monitored
closely.

Monitor all medications for the Antiplatelet medications can Aspirin was monitored carefully.
potential to increase bleeding, increase the risk of bleeding in
including aspirin. high-risk clients (Ackley and
Ladwig, 2014).

*Encourage patient to drink a lot of This will help to flush the bladder. Patients urine changed from a
fluid. darker pink to a lighter pink.
University of South Florida College of Nursing Revision September 2014 20
Avoid over distention of bladder *Encourage patient to void when
urge is noted.
Voiding with urge prevents urinary Patient voided when urge was
retention which may cause over noted.
distention of the bladder. Over
distention of the bladder can lead
to hemorrhage (Ackley and
Ladwig, 2014).

*Encourage the patient to decrease This will prevent urinary retention Patient had bathroom availability.
the intake of fluids when there is and bladder distention for long
no bathroom availability. periods of time.

Ambulate early to prevent Encourage patient to ambulate to Bleeding may cause thrombosis to Patient was able to ambulate to the
thrombosis and subsequent the bathroom, to the chair, and occur. Movements decreases the bathroom, to the chair, and around
embolism around the unit. risk of thrombosis and embolism. the unit.

Have the patient keep a record of
the number of times he ambulated
and the distance walked.
This will give an idea of the
activity level of the patient.
The patient was able to walk
around the unit about four times at
different intervals within 4 hours.
He was also able to move around
his room.

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

University of South Florida College of Nursing Revision September 2014 21

 References

Ackley, B.J. & Ladwig, G.B. (2014). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Bladder Cancer WebCafe. (2009). Nutrition. Retrieved from http://blcwebcafe.org/nutrition.asp

Huether, S. E. & McCance, K. L. (2012). Understanding Pathophysiology. Missouri: Elsevier.

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for

practice (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.

Treas, L.S. & Wilkinson, J.M. (2014). Basic Nursing Concepts, Skills & Reasoning. Philadelphia: F.A. Davis

Company.

United States Department of Agriculture. (2016). SuperTracker: Food Tracker. Retrieved from

https://www.supertracker.usda.gov/foodtracker.aspx

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University of South Florida College of Nursing Revision September 2014 23