UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Maria Sofia Quinonez

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.

Assignment Date: 11/8/2015

Patient Initials: DJT

Age: 55

Agency: Veterans Hospital (Spinal Cord Injury

Unit)
Admission Date: 10/15/15

Gender:

Marital Status: Single

Primary Medical Diagnosis: Multiple Sclerosis

1 PATIENT INFORMATION
Female

Primary Language: English

Level of Education: Bachelors Degree
Occupation (if retired, what from?): Journalist/ Photographer and RN

Other Medical Diagnoses: Left Breast Cancer

(Invasive Ductal Carcinoma)

Number/ages children/siblings: No children; 3 brothers, 2 sisters

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

Code Status: Full Code

Living Arrangements: Lives alone, main caregiver is her mother.

Advanced Directives: Yes, living will

Culture/ Ethnicity /Nationality: African American

Religion: Baptist, but now is nondenominational

Surgery Date: 10/20/15 Procedure: bilateral

mastectomy
Type of Insurance: AARP

1 CHIEF COMPLAINT: They found a lump in my left breast that was positive for breast cancer, so I had
to come in to get it removed. The doctor recommended removing both breasts incase of a recurrence of the
cancer. So now I am just recovering from the surgery.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Patient was admitted on 10/15/15 to prepare for surgery of a double mastectomy on 10/20/15. Patient was found
with an invasive ductal carcinoma, where a 4 cm mass grade 3 and a 1.3 cm mass grade 2 were found in the left breast on
8/5/15. Patient also has advanced stages of Multiple Sclerosis and is wheelchair- bound with a suprapubic catheter in
place. Two weeks later, patient is currently recovering well, surgical drains have been removed and sutures are intact with
no redness or swelling noted. Patient says pain from surgery has improved drastically; she still had some pain in her breast
and axillary area mainly where the masses were excreted. Patient describes the pain as sore and annoying. Currently the
most effective medication for patients pain relief is hydrocodone. Bacitracin/Neomycin/Polymyxin B Ointment on the
sutures also helps soothe the aches and patient describes the least pain as a 3 and worst pain at an 8 on the post-op
mastectomy site. Patient is satisfied with patient care and it will be continued until patient is healed and discharged to go
home. Patient refused nursing home care, so just waiting on the clear to be sent home, once sutures from the surgical site
are completely healed.

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

Father

71

Mother

69

Brother

51

Sister

53

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Cause
of
Death
(if
applicable
)

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

1/15/15

Environmental
Allergies

Operation or Illness
Left Breast cancer, left breast lump noticed on an ER visit on 8/5/15. A bilateral mastectomy was
surgically done to remove the 4cm mass within the lateral margin of the left breast. Hydrocodone was
given for pain and Bacitracin/Neomycin/Polymyxin B Ointment given to treat the wounds from the
surgery.
Multiple Sclerosis- Diagnosed at age 24, has advanced to loss of all four extremities. Patient is now a
quadriplegic with a hyper-reflexic neurogenic bladder and a suprapubic catheter. Patient takes
Baclofen, Gabapentin, Tizandine, Clonazepam, and Lamotrigine to treat symptoms caused by MS,
such as spasms, pain, and stiffness.
Excision lesion on right foot- mole on foot was found and removed for potential for skin cancer.

Alcoholism

Date
10/20/15

relationship
relationship
relationship

Comments: Include age of onset

University of South Florida College of Nursing Revision September 2014

 1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service U
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? 5/7/2010
Influenza (flu) (Date) Is within 1 years? 2/2/2010
Pneumococcal (pneumonia) (Date) Is within 5 years? 8/28/2015
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
1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

Other (food, tape,

latex, dye, etc.)

NAME of
Causative Agent

NO

Type of Reaction (describe explicitly)

Iodine
Monosodium
Glutamate
Reglan
Sulfa Drugs

Watery eyes, throat closes, rash and swelling

Shellfish
MSG

Throat closes, puffy and itchy eyes

Migraines

Whelps, and throat swells up

Hives and difficulty breathing
Hives and swelling of the face, tongue, and lips

University of South Florida College of Nursing Revision September 2014

 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) Left breast carcinoma with multiple small axillary lymph nodes: The breast cancer etiopathogenesis
is that invasive cancers arise through a series of molecular alterations at the cell level. These alterations result in
breast epithelial cells that have uncontrolled growth and eventually develop into a tumor. Evaluation of breast
cancer includes a clinical examination, imaging and a needle biopsy. There are many risk factors related to
breast cancer other than old age and family history. About 5% if women with breast cancer carry a mutation in
one of the two known breast cancer genes, BRCA1 and BRCA2 (Breast Cancer, 2012). Early menarche, late
menopause, or late first pregnancy also increases the risk. It has also been found that taking oral contraceptive
use increases rick very slightly, higher in women who start using it before age 20. The number of disease
subtypes of breast cancer is still unknown but the ones found generally align with the absence of estrogen
receptor, progesterone receptor, and human epidermal growth factor receptor 2 (Moore 2014). Breast cancer
prognostic factors include axillary lymph node status, tumor size, lymphatic/vascular invasion, patient age,
histologic subtypes, and response to neoadjuvant therapy. Many times cancerous development of the lymph
nodes in the axilla is an indication of the likelihood that the breast cancer has spread to other organs. Also the
following physical findings such as a lump or contour change, skin tethering, nipple inversion, or dilated veins
should raise concern. Pathologic review of the tumor tissues for histologic grade, along with the ER/PR status
and HER2 status are all necessary for determining the proper treatment (Breast Cancer 2012). Surgery is
considered the primary treatment to remove the tumor in early-stage breast cancer. Many patients are cured with
surgery alone if caught on time. Adjuvant treatment of breast cancer is designed to treat micrometastatic
disease, which is where breast cells have escaped the breast but have not yet established identifiable metastasis.
This could be a potential risk so after removal of the tumor patients might receive radiation therapy and
systemic therapy depending on the severity of their cancer.

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name albuterol/ ProAir HFA

Concentration: inhalation

Route Oral

Dosage Amount: 1 inhalation

Frequency: 4 times daily, 1 inhalation every 4 to 6 hours

Pharmaceutical class: bronchodilator

Hospital

Indication: increases airflow to the lungs

Adverse/ Side effects: Shakiness in legs and arms, increased HR, difficulty breathing, hypokalemia, bronchospasms
Nursing considerations/ Patient Teaching: seek medical attention if asthma medications stop working
Name baclofen/ Lioresal

Concentration mg

Route: Oral

Dosage Amount 20 mg
Frequency: 3 times daily

Pharmaceutical class: muscle relaxer and antispastic agent

Both

Indication: used to treat muscle symptoms caused by MS including spasms, pain, and stiffness
Adverse/ Side effects: seizures, confusion, hallucinations, drowsiness, headache, nausea, uneven heartbeat
Nursing considerations/ Patient Teaching: may impair thinking and cause confusion so do not operate machinery; do not stop abruptly
Name gabapentin/ Gralise

Concentration: mg

Route: oral

Dosage Amount: 200 mg

Frequency: Twice daily

Pharmaceutical class: Anticonvulsant

Both

Indication: used for seizures

Adverse/ Side effects: increased seizures, fever, skin rash, confusion, bruising, changes in behavior, dizziness
Nursing considerations/ Patient Teaching: check patient for kidney or liver disease; some have thoughts of suicide, caregivers should be alert to changes in mood
or symptoms.

University of South Florida College of Nursing Revision September 2014

Name: tizanidine/ Zanaflex

Concentration: mg

Route: oral

Dosage Amount: 4 mg
Frequency: three times daily

Pharmaceutical class: short-acting muscle relaxer

Both

Indication: block nerve impulses (pain sensations) that are sent to the brain; relaxes muscle tone
Adverse/ Side effects: fainting, hallucinations, confusion, stomach pain, dark urine, slow heart rate
Nursing considerations/ Patient Teaching: do not take with the antidepressant Luvox or the antibiotic Cipro. Do not use at a time when muscle tone is needed to
assure safe balance and movement. Do not take more than 3 doses (36 mg) in a 24 hr period because it can cause liver toxicity.
Name: allopurinol/ Zyloprim

Concentration: mg

Route: oral

Dosage Amount: 300 mg

Frequency: once daily

Pharmaceutical class: Xanthine Oxidase Inhibitor

Both

Indication: treat high uric acid levels in the blood that may be caused by cancer medicines
Adverse/ Side effects: joint stiffness or swelling, rash, abdominal pain, bleeding gums, bloody stool.
Nursing considerations/ Patient Teaching: increase fluid intake when taking this drug. This drug can also lower blood cells that help with fighting infections.
Avoid drinking alcohol.
Name: clonazepam/ Klonopin

Concentration: mg

Route: oral

Dosage Amount: 0.25 mg

Frequency: once daily

Pharmaceutical class: Benzodiazepine

Both

Indication: to treat seizure or panic disorder

Adverse/ Side effects: confusion, unusual risk-taking behavior, fluttering in chest, drowsiness, dizziness, weak or shallow breathing
Nursing considerations/ Patient Teaching: Should not use this medicine if you have severe liver or kidney disease. Sedative effects of drug may last longer in
older adults. Accidental falls are common on benzodiazepines.
Name: hydrochlorothiazide/ Aquazide H

Concentration: mg

Route: oral

Dosage Amount: 12.5 mg

Frequency: once daily

Pharmaceutical class: thiazide diuretic

Hospital

Indication: helps prevent body from absorbing too much salt, which causes fluid retention. Helps prevent edema.
Adverse/ Side effects: eye pain, dry mouth, drowsiness, muscle pain, numbness or tingling feeling, nausea
Nursing considerations/ Patient Teaching: avoid alcohol, many drug interactions so tell doctor of other medications used. Avoid becoming overheated or
dehydrated during exercise and in hot weather.
Name: oxybutynin chloride/ Ditropan

Concentration: mg

Route: oral

Dosage Amount: 10 mg
Frequency: twice daily

Pharmaceutical class: antispasmodics

Both

Indication: used to treat certain bladder and urinary conditions for an overactive bladder
Adverse/ Side effects: dry mouth, drowsiness, blurry vision, constipation, unusual taste in mouth
Nursing considerations/ Patient Teaching: should not use his drug if you have uncontrolled narrow-angle glaucoma. This medication can decrease perspiration
and pt can be more prone to heat stroke.
Name: lamotrigine/ LaMICtal

Concentration: mg

Route: oral

Dosage Amount: 100 mg

Frequency: once daily

Pharmaceutical class: anti-epileptic

Both

Indication: for epileptic seizures related to patients MS

Adverse/ Side effects: skin rash, low blood cell counts, dizziness, dry mouth, blurred vision, fever, chills, unusual bleeding
Nursing considerations/ Patient Teaching: may cause a severe or life-threating skin rash seek medical attention immediately.
Name: bacitracin/neomycin/polymyxin B- Medi-Quik

Concentration: n/a

Route: topical

Dosage Amount: small amount

Frequency: twice daily

Pharmaceutical class: antibiotics

Hospital

University of South Florida College of Nursing Revision September 2014

Indication: used to treat wounds from post-op double mastectomy and to prevent infections of the skin
Adverse/ Side effects: itching, skin rash, redness, swelling, loss of hearing
Nursing considerations/ Patient Teaching: do not used medication if allergic. Ask doctor is it is safe to take medication if pt has medical conditions such as
chronic ear infection or ruptured ear drum.

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? Regular
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet: Regular
Patient eats a normal diet at home, with mainly fruits and
veggies and occasional meats. Patient states she eats mainly
chicken as her main meal and always accompanies that
with beans, rice, or potatoes. Patient eats a yogurt a day
with any meal of her preference. Patient drinks a lot of
juice, but overall has a solid and nutritious diet.
According to MyPlate, females about 51 should eat 1
cups of fruit daily. As the graph portrays, the patient is
receiving less than the recommended amount. Patient is
receiving more than the necessary amount of vegetables
that is good in maintaining a healthy and balanced diet.
Patient needs to increase her intake of diary products,
maybe add a glass of milk a day to keep calcium an
important part of her diet. Patient also mentioned not
including a lot of fish in her diet, which she should try to
find a way to at least eat fish twice a week. The patient does
not watch her sodium intake, which she should since she is
at risk for hypertension. The protein intake of the patient is
more than needed, so maybe look at balancing out the
protein in her diet and focus on the other fields that need
more attention. Patient also has a sweet tooth, evident by
her snacking on chocolate bars at least 3 to 4 times weekly.
Overall, with a non-restricted diet, the patient maintains a
healthy diet of course tending to her wants but also making
healthy choices throughout.
Breakfast: 2 scrambled eggs, 1 cup of grits, cup of fruit, 1
8oz mug of coffee

Lunch: 11/2 cups of veggies, 5 slices of pork, 1 cup of

potatoes, 1 serving of strawberry yogurt
Dinner: 2 cups of tomato soup, 1 chicken breast, 2 cups of
buttered noodles. 1 serving of an apple cinnamon muffin
Snacks: chocolate bar

University of South Florida College of Nursing Revision September 2014

Liquids (include alcohol): fruit drinks, water, coffee,

lemonade, soda (occasionally)
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? Mother and sister Lisa
How do you generally cope with stress? or What do you do when you are upset?
Patient listens to music (Jazz, soul and rock n roll) to help her calm down.
Patient also meditates and relaxes daily.
Patient likes being by herself and sleeping most of the day since she cant do physical activity.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Getting used to being in hospital and loss of motivation. Patient wants a male partner for company. Feels lonely and
mother is annoying, wants her to care from far away. Patient also struggles with sleep apnea. Patient states, I just want
a new life.

+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? Yes, with brother and ex-husband
Have you ever been talked down to? Yes, by her mother. Have you ever been hit punched or slapped? By ex-husband
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? Yes, exhusband. If yes, have you sought help for this? Went to speak to a minister.
Are you currently in a safe relationship? n/a

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: Since my patient is 55 years old, she in the Ericksons developmental stage of Generativity vs. Self
absorption/Stagnation. Career, family, and work are the most important things at this age of 35 to 65. Middle adulthood can also be a
time in someones life where people take on great responsibilities and control in their life. Eriksons idea of generativity is attempting
to produce something that makes a difference in society and it is the concern of guiding the next generation. Major life shifts can occur
during this stage, so many people struggle with finding their purpose. In contrast, a person who is self centered and unable or

University of South Florida College of Nursing Revision September 2014

unwilling to help society move forward develops a feeling of stagnation, which is a dissatisfaction with the relative lack of
productivity. (Psychosocial Stages, 2013)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: My patient
shows signs of self absorption/stagnation because due to her Multiple Sclerosis has slowly been dealing with losing movement in all
four extremities. This disease as gradually slowed her life down and prevented her from attempting to make a difference in society.
She also regrets not starting a family or having a male partner at the moment. She has tension with her mother and very distant
relationships with her siblings. At one point before her disease, she was making a difference working for the military as a journalist
and photographer, patient really looks back to that time as the best in her life. She has no motivation to guide the next generation
because she really has no family to guide or help them grow. Patient tries to stay positive amongst her debilitating disease and tries to
make a difference in her own world the best way she can. Her recent diagnosis of breast cancer and removal of both breasts has also
setback the patient, and caused her to have an altered body image.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: Multiple Sclerosis
has slowed patient down and taken her way of life. Patient is sick of watching tv and being in the same position in the hospital. Patient
states I am existing, but not really living.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Just luck, it came about. I dont blame anyone, but science.
What does your illness mean to you?
My illness means loss of independence and loss of well-being. Multiple Sclerosis affects everyone differently, I am
blessed because I have seen a lot worse.

+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? Men
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No
Are you currently sexually active? No If yes, are you in a monogamous relationship? n/a
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Birth control
How long have you been with your current partner? N/A
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

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10

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

What importance does religion or spirituality have in your life? Means everything to patient, is a preachers kid. Religion has been part
of patients life forever. She prays every morning and every night.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? Yes, makes it easier and makes patient stronger.
______________________________________________________________________________________________________

+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? Cigarettes/cigars
How much?(specify daily amount)
Been over 20 years since her last one

Yes on occasion
For how many years? 4 years
(age 25

thru

29 )

If applicable, when did the

patient quit?

Pack Years: n/a

Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes, and never going
back
If yes, what did they use to try to quit? N/a

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer, occasionally
How much?
Volume: 1 to 2 beers
Frequency: once a week
If applicable, when did the patient quit?

For how many years?

(age 24 thru present)

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
If so, what? Marijuana, a couple joints in her life
How much? 5 times in her life
For how many years?
(age 20

Is the patient currently using these drugs?

No

thru

n/a

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

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11

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? Good health except for not being able to walk or feel legs anymore. They caught my breast
cancer early, so I am healing well.

Integumentary: Skin is intact, wounds from mastectomy are healing, no redness or swelling noted. Has alopecia.
HEENT: difficulty seeing, legal blindness
Pulmonary: difficulty breathing
Cardiovascular: regular heart sounds
GI: GERD, history of polyp of colon
GU: Neurogenic bladder, suprapubic catheter, frequent urinary tract infections
Women/Men Only: Inflammatory disease of cervix, vagina, and vulva, had sling surgery in 2004
Musculoskeletal: weakness and pain in all four extremities
Immunologic: enlarged lymph nodes in axillary
Hematologic/Oncologic: anemia
Metabolic/Endocrine: Type II diabetes; osteoporosis
Central Nervous System: migraines and seizures
Mental Illness: depression
Childhood Diseases: n/a

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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12

10 PHYSICAL EXAMINATION:
General survey: Patient is a 55 year old female with advanced stages of MS, recovering from a bilateral mastectomy.
No visible signs of distress and patient is alert.
Height: 175.26 cm Weight 234 lbs. BMI: 35.6 Pain (include rating and location) 8- lower back Pulse: 102 Blood
Pressure (include location) 134/55 (right arm) Temperature (route taken) 98.1 oF (orally)
Respiration: 13 SpO2 99% Room Air
Overall Appearance: skin normal for ethnicity, dry skin, sutures in tact from post op-mastectomy. Patient is overall
clean and maintains eye contact.
Overall Behavior: alert and oriented x3, appropriate. Patient had no fears, concerns, or anxieties. Patient is
lethargic, but relaxed
Speech: normal and clear. No slurred words
Mood and Affect: Patient appears to be talkative and a bit hostile when talking about past experiences
Integumentary: dry skin, sutures in tact. Skin turgor is elastic. Capillary refill <3 seconds. No rashes or lesions
evident
IV Access: left femoral, heplock. Patent, no inflammation, redness, edema, no tenderness.
HEENT: facial features symmetric. Conjunctivas clear with no discharge, eyes appear to be spontaneous. Pupils
equal and reactive bilaterally. Size: Left: 3 mm Right: 3mm, EOM intact through 6 cardinal field without
nystagmus. Ears symmetric without lesions, whisper test heard bilaterally. Nose without lesions or discharge. Mouth
pink and moist without lesions
Pulmonary/Thorax: respirations regular and lung sounds normal. No cough, chest expansion symmetric
Cardiovascular: heart sounds are regular, S1 and S2 detected, no murmurs, clicks, or abnormal heart sounds.
Brachial and Radial pulses 2+ equal bilaterally. Edema +1 in all four extremities. No carotid bruits heard.
GI: bowel care QOD w/magnetic bullet. Bowel sounds normal and active x4 quadrants, no unplanned accidents.
Abdomen is soft. Last BM: 11/2/2015
GU: Hyper-reflexic neurogenic bladder: suprapubic catheter. Urine Output: 1500 ml, urine: clear yellow
Musculoskeletal: weakness and pain in lower and upper extremities. No movement in all 4 extremities
Neurological: Patient awake, alert, and oriented to person, place, time and date. Sensation intact to touch and pain.

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
WBC: 10.72

Dates
(10/21/15)

11.40
Normal (4.3-10.8)

(11/2/15)

RBC: 3.9

(10/21/15)

4.0
Normal (3.8-5.2)

(11/2/15)

Trend

Analysis

One day after post-op

surgery, WBC was elevated,
but normal for surgery
indicating
inflammatory
process is occurring at
surgical site.

High WBC count is an increase

in disease fighting cells
circulating in the blood. It
could indicate an infection,
stress, inflammation, trauma,
or allergy. If high WBC
continues, it requires further
investigation.
RBC is in normal range states
that patient does not have
anemia. Anemia can be
classified by the size of RBCs,
the amount of hemoglobin
contained within the RBCs
and pathologic process causing
anemia.

RBC count remained in

normal range post-op
surgery until two weeks
after.

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13

HGB: 10.4

(10/21/15)

10.8
Normal (12-15)

(11/2/15)

IG #: 0.05

(10/21/15)

0.07
Normal: (0-0.05)

(11/2/15)

Lymph #: 2.46

(10/21/15)

2.95
Normal: (1.18-3.41)

(11/2/15)

Na: 138

(10/21/15)

136
Normal: (136-145)

(11/2/15)

HGB levels are

significantly lower than
the normal range post-op
surgery and two weeks
later indicating that
patient is anemic.

Low HGB levels are associated

with anemia. Causes of anemia
can be nutritional,
gastrointestinal, or blood loss
from trauma or surgery, most
likely from this patients case
from double mastectomy
surgery. (Hemoglobin Levels
2014)

IG levels are increasing

slightly after surgery,
which could indicate an
acute infection at the
surgical site. .

Immature granulocytes include

neutrophilic metamyelocytes,
myelocytes, and
promyelocytes. Increased
values are associated with
acute infection, inflammatory
responses, or
myeloproliferative disorders.
(Hemoglobin Levels 2014)

Lymph # seem to be in
normal range post-op and
two weeks surgery. No
concern for patient.

A high percentage of
lymphocytes on a CBC
can indicate chronic
bacterial infection,
infectious hepatitis. So a
normal range is good
considering patient just
got out of surgery and no
infection is detected.
If sodium levels get too
low hyopnatremia can
occur. Patient might be
drinking too many fluids
or experiencing kidney
failure. If levels drop
below normal in next labs
patient needs to take fluid
restrictions.

Sodium levels are in

normal range, but tend to
be towards the bottom of
the spectrum both times
labs were taken.

Other labs taken not related to hospital stay:

K: 4.1(10/21/15) and 3.5(11/2/15) within normal range of 3.5-5.2
Cl: 107 and 102, within normal range of 98-109
CO2: 23 and 25 within normal range of 22-32
BUN: 9 and 10 within normal range of 6-20
CREAT: 0.6 and 0.7 within normal range of .6-1

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14

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is just currently recovering from double mastectomy surgery. Surgical drains have been safely
removed and sutures are healing nicely. Patient came back with high WBC count and might be at risk for
infection, so just waiting to heal and get discharged. Patient is on no special diet at the hospital. Patient reports
that the combination of the pharmacological and nonpharmacological therapy (repositioning and distraction) was
75% effective in reducing pain to a level at which rest and goals for ADL (walking, deep breathing,
rehabilitation) were met. Patient is satisfied with current plan of care and will continue it until discharged. Patient
is also due for an eye exam on 11/22/15 and a medication reconciliation as soon as possible.

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

1. Disturbed body image related to loss of sexually significant body part
2. Impaired physical mobility related to neuromuscular impairment.
3.
4.
5.

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 15 CARE PLAN
Patient
Goals/Outc
omes
Patient will
be
repositioned
every 4
hours to
relieve
stress on
sides of
body and
decrease the
risk of
developing
pressure
ulcers.

Nursing Diagnosis: Impaired physical mobility related to neuromuscular impairment.

Nursing
Rationale for
Evaluation of Goal on Day Care is Provided
Interventions to
Interventions
Achieve Goal
Provide References
1. Help patient 1. The abilities of the
1. The patients abilities were assessed for her post-op recovery and in a week patient will
with all daily
patient should be
be able to get out of bed rest.
activities she
assessed to determine
needs, but let
what the correct plan of
2. Patient is repositioned when feeling discomfort and she still remains on bed rest
her do as much action will be in keeping for the next week.
as she can
her safe throughout her
without feeling stay in the hospital.
3. Patient has found the best position to fall asleep in and no pressure ulcers have been
any pain.
detected.
2. Patient is recovering
2. Since patient from post-op of a
is a
bilateral mastectomy so
quadriplegic,
shes been on bed rest for
make the bed
the last 3 weeks.
as comfortable Discomfort is one of her
as possible to
main concerns, so she
avoid
should be repositioned as
discomfort for much as possible in the
the long hours state that shes in at the
she will be
moment.
laying down.
3. Patient has difficulty
3. Reposition
breathing at night, so
patient as
repositioning her upright
much as
and checking up on her
possible to
every couple hours is a
help with
necessity to keep the
breathing and
patient healthy and
make sure
without pain.
patient has
Repositioning with many
access to
MS patients, helps
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everything she
needs to call
for help.
Patient will
be able to
go on
electric
wheelchair
and go
outside to
get a change
of scenery
from her
hospital
stay.

1. Patient will
continue to heal from
double mastectomy as
doctors orders, and if
plan of care is
successful patient will
be able to get off of
bed rest.

1. Patient has been taking

medications and applying
ointment to her surgical
sutures, and if all goes as
planned patient will be
able to be discharged and
headed home on electric
wheelchair.

2. Patients attitude
about getting better
will be more positive
and a positive mood
will be implemented
for her to do the one
thing shes been
wanting to do since
surgery, ride her
wheelchair again.

2. Patient needs to
surround herself with
positive people because
the progressiveness of
this disease is only going
to get worse. Whatever
makes the patient happy
and is within her limits
should be given to her in
moderation to keep her
safe and content.

3. Multiple Sclerosis
has impaired many of
patients daily
functions, but the
feeling of
powerlessness wont
restrict her from being
discharged in a week.
Patient will
receive
physical
therapy in

decrease the risk of

pressure ulcers.

1. Physical therapist
will be contacted to
not only start care in
the hospital, but

3. Patient is still healing

well two weeks after
surgery, but her MS
slows down the healing
process. Moving patient
at least out of the bed
will give her a sense of
hope.
1. Physical therapy
although may not cure
disease, will assist in
alleviating pain of the

1. Patient is still on bed rest, but at the rate she is going she should be discharged very soon
once her WBC count is at a normal range and her sutures are healed.
2. Patient still remains on bed rest, but hopefully she will be cleared in a week to ride her
wheelchair outdoors.
3. Patient still feel like she cant do anything for herself, but her positive attitude will get her
out of bed rest soon.

1.Physical therapist was not contracted because patient cannot afford

the proper care at the moment.
2.Mother agreed to help, but patient refuses the help from her mother.

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upper
extremities
where she
can still
slightly
move and
get more
blood
circulated to
those areas.

continue at least once

or twice a week once
at home.
2. Caregiver (mother)
should also massage
or move upper and
lower extremities of
patient often to get a
little activity in.

Patient will
understand
keeping a
safe
environment
and having
a caregiver
close to
continue
proper
healing
from
surgery and
ease pain
from MS
disease.

1. Recommendations
to put patient in a
nursing home will be
implemented into
discharge planning,
since patient states she
lives alone and needs
help with daily
activities.
2. Talking to main
caregiver of
convincing patient to
seek help at home if
patient does not
support nursing home
option.

patient and putting stress

elsewhere.
2. If caregiver helped
patient with movement
the disease might seem a
little bit more bearable to
patient, allowing her to at
least get some blood flow
to her lower and upper
extremities.
1. Putting patient in a
nursing home, would
help her with her daily
activities and make her
life a lot more bearable
compared to the
conditions she has at her
home currently.

1. Patient is currently refusing nursing home care after discharged from hospital, because
she doesnt want to lose the little independence she still has. Patient knows its the right thing
to do at this moment in her life.
2. Patients mother has already looked up the best nursing home for the patient and the
accommodations she wants if she doesnt eventually decide to go to one.

2. The patients main

caregiver doesnt have a
good relationship with
patient, so maybe the
nursing home option
would be the best for
both of them.

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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
XMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
XRehab/ HH
Palliative Care

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References
Ackley, B.J & Ladwig G.B (2011) Nursing Diagnosis Handbook St. Louis MO: Mosby Elsevier
Davis, Charles Patrick (11/12/2014) Hemoglobin Levels
Retrieved from: http://www.emedicinehealth.com/hemoglobin_levels/page4_em.htm
Kosir, Mary Ann, (2012) Breast Cancer Retrieved from:
http://www.merckmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-cancer
McLeod, Saul, (2013) Psychosocial Stages, Retrieved from: http://www.simplypsychology.org/Erik-Erikson.html
Moore C.F Halle, (September 2014) Disease Management of Breast Cancer, Retrieved
from:http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematology-oncology/breast-cancer/

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