UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Maria Sofia Quinonez

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials: JWT

Age: 65

Gender: Male

Marital Status: married

Assignment Date: 11/9/16

Agency: James A.Haley Veterans

Hospital
Admission Date: 10/25/16
Primary Medical Diagnosis: Fever, and possible
infection from whipple procedure

Primary Language: English

Level of Education: college (bachelors degree)

Other Medical Diagnoses: n/a

Occupation (if retired, what from?): retired engineer

Number/ages children/siblings: 4 children/siblings- 3 alive, 2
deceased

Served/Veteran: Yes
If yes: Ever deployed? Yes

Code Status: DNR

Living Arrangements: lives with wife in one-story house

Advanced Directives:
If no, do they want to fill them out? No.
Surgery Date: 10/5/16 Procedure: whipple
procedure

Culture/ Ethnicity /Nationality: American

Religion: Baptist

Type of Insurance: self-insureed

1 CHIEF COMPLAINT: RUQ pain and fever. Fever has subsided and patient wants to go home.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) Patient is a 65 year old male who was recently admitted on 10/25/16 complaining of RUQ pain and bloating that
started 3 days ago. Patient also noticed a temperature of 101.4 the day before coming to the ED. Patient underwent a
Whipple procedure for preiampullary carninoma mass with CBD destruction on 10/5/16 and he is worried that his pain
and fever might be related to the procedure 2 weeks ago. Patient is able to tolerate food and liquids without any issues and
has regular bowel movements. WBC levels on 10/26/16 were elevated (14.14) and patient is currently on antibiotics to
lower WBC count within normal limits.

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
10/5/16
6/13/05

Father

67

Mother

87

Brother

64

Sister

46

relationship

66

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

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)
Heart
attack

Alcoholism

Whipple procedure
Knee surgery
Hypertension
GERD
Osteoarthritis
Hyperlipidemia

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

cancer

relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? Yes, 2 years ago
Influenza (flu) (Date) Is within 1 years? Yes this year

YES

University of South Florida College of Nursing Revision September 2014

NO

Pneumococcal (pneumonia) (Date) 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
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Statins

Type of Reaction (describe explicitly)

Liver enzymes increase out of normal range

Medications

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) Preiampullary carcinoma is a group of neoplasms that are found in the head of the pancreas, the
distal common bile duct and the duodenum. Thus this type of cancer may show intestinal and pancreatobiliary
morphology (Cruz, 10). The overall pattern of mutation in ampullary carcinoma more closely resembles that of
colorectal than pancreatic cancer. The strategic location of these neoplasms may cause early biliary obstruction
with jaundice, biliary colic, bleeding or pancreatitis. Serum bilirubin and transaminase are typically elevated
enzymes. An ultrasonography confirms the type of biliary obstruction and an endoscopic ultrasound (EUS) can
show the tumor extension into the wall of the duodenum. The most common symptoms are abdominal pain,
iron-deficiency anemia, weight loss, nausea and vomiting and jaundice. There is a five year prognosis for this
type of cancer and it is more favorable for patients with duodenal cancer, followed in declining order by
ampullary tumor and distal bile tumor. For any preiampullary malignancies, resection is the best hope for longterm survival (Cruz, 13). A pancreaticoduodenectomy with or without a whipple operation pylorus preservation
is the procedure of choice for these malignant tumors. Patients also can later receive radiation therapy with
chemotherapy if needed.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: Heparin Injection

Concentration: units

Route: subcutaneous

Dosage Amount: 5,000 units

Frequency: Q8H 3X a day

Pharmaceutical class: anti coagulant (blood thinner)

Both

Indication: Used to treat and prevent blood clots in the veins, arteries, or lung. Also used before surgery to reduce the risk of clots.
Adverse/ Side effects: abdominal pain, blood in urine, headaches, constipation, coughing up blood, chest pain, blood under the skin(blood blister), or black
tarry stools
Nursing considerations/ Patient Teaching: Heparin can cause one to have bleeding episodes while you are using it and for severeal weeks after you stop. NSAIDS
can increase risk for bleeding while on heparin. Stop using heparin and call provider if any signs of stroke are present.
Name: piperacillin/tazobactam, Zosyn

Concentration: grams in 100 mL

Route: IV piggyback

Dosage Amount: 4.5 grams

Frequency: Q8H and infused over 240 minutes

Pharmaceutical class: antibacterial agent

Hopsital

University of South Florida College of Nursing Revision September 2014

Indication: It works by blocking the bacterias cell wall growth, which kills the bacteria
Adverse/ Side effects: dizziness, diarrhea, may reduce platelet count, headache, chest pain, bloody stools, agitation, bone pain
Nursing considerations/ Patient Teaching: Hormonal birth control may not work as well on this medication, make sure to finish the full course of treatment, this
medication may also increase blood sugar, and avoid alcohol.
Name: alprazolam, Xanax

Concentration: mg

Route: oral

Dosage Amount: 0.25 mg

Frequency: once a day

Pharmaceutical class: benzodiazepine

Both

Indication: It affects chemicals in the brain that may be unbalanced in people with anxiety. It is used to treat anxiety disorders, panic disorders and anxiety
caused by depression
Adverse/ Side effects: sedation, constipation, weight gain, nervousness, headache, skin rash, memory impairment, blurred vision and fatigue
Nursing considerations/ Patient Teaching: do not use if you are pregnant, Misuse od this medication can cause addiction, overdose or death, avoid alcohol and
you should not take this medication if you have narrow-angle glaucoma or if you are taking itraconazole.
Namea; tamsulosin, Flomax

Concentration: mg

Route: oral

Dosage Amount: 0.4 mg

Frequency: once a day

Pharmaceutical class: alpha-blocker

Both

Indication: It relaxes the muscles in the prostate and bladder neck, making it easier to urinate
Adverse/ Side effects: dizziness, nausea, headache, blurred vision, decreased libido, severe skin reaction
Nursing considerations/ Patient Teaching: This medication may cause dizziness or fainting at first so be careful operating a vehicle. Many drug interactions such
as alfuzosin and doxazosin, and contact doctor immediately if you experience penis erection that is painful or lasts more than 4 hours.

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? Normal
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Normal healthy diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: eggs, energy drink or smoothie, yogurt, or
ensure.

The patient recently switched over to a healthier diet within

the last year. With his goal to lose 70 pounds he has slowly
been making changes in his diet. He is consuming too much
protein and not enough fruits from what was recorded of 24
hr average healthy diet. He says he always tries to include
vegetables in his diet as well as a daily ensure shake to get
his daily nutrients. According to MyPlate, this patient is
still not meeting the full requirements for key components
of a healthy diet such as refined grains and vegetables. The
patient also is consuming an excess amount of sodium,
which he has to monitor since he has a history of
hypertension and hyperlipidemia. Overall, starting with
adding a simple banana in the morning to his diet or an
apple instead of icecream as a snack would make sure he is
getting the correct amount of nutrients to maintain his
health diet and keep the weight off.
Lunch: sandwich, soup or salad
Dinner: grilled chicken or fish, fresh veggies, and rice
Snacks: ice cream or pudding
Liquids (include alcohol): water mostly and beer once in a
while.

University of South Florida College of Nursing Revision September 2014

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
How do you generally cope with stress? or What do you do when you are upset?
I usually eat a lot or watch tv when Im stressed

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
The hospital life, Ive never been this sick and its taking a toll on my body.

+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: Ego Integrity vs. Despair is the final psychosocial stage and it is mainly where people reflect back on their life.
People look back on all their experiences throughout life and determine if they are happy and have grown or if they regret thing things
they did or didnt do (Cherry, 2015). Those who enter the despair phase of this stage have many regrets and are not content with their
life. Those individuals who feel proud of their accomplishments will have sense of integrity. Everyone experiences regret at some
point in their life, but in the phase of Ego integrity, people have a general feeling of satisfaction and they will attain wisdom even
when confronting death(Cherry, 2015).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: I feel like
my patient is in the Ego Integrity phase. Although he was diagnosed with cancer and underwent a very serious procedure, he still has
high spirits in continuing on with life at his highest potential. The doctors were able to remove all of his caner during the whipple
procedure and this has then lifted his spirits. He has a very strong faith and support system that has made these last couple of months
easier to endure. Through it all entire patient has little regrets on life and still views himself as the head of the family with many duties

University of South Florida College of Nursing Revision September 2014

to uphold.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: The patient has
always been someone the family looks up to and he feels that now with his sickness he cant be that man for his family. The
complications due to such a big procedure are making his life difficult right now. He is relieved that his infection wasnt anything
serious and wants to get out of the hospital so he can continue to live his life normally.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
None really knows why you get cancer.
What does your illness mean to you? My outlook on life is not as positive as before.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes.
Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? No.
Have you or your partner received the Gardasil (HPV) vaccination? Yes, my partner.
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? Condoms.
How long have you been with your current partner? 37 years
Have any medical or surgical conditions changed your ability to have sexual activity? No, just my whipple procedure
now.
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? It is the number 1 thing in my life always.
Do your religious beliefs influence your current condition? Yes of course, when Im done with this life I know where Im going.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)

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? NO.

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
What? Beer
How much? 1 beer a week
Volume: 12 fl oz.
Frequency: once a week
If applicable, when did the patient quit?

For how many years? 30

(age 35

thru

now )

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? 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? N/A

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 no
SPF:
Bathing routine: couple times a week
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? 4 months 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: O+
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 6 x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
1 x/day
1 x/year

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? 10/25/16
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 10/5/16

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? yearly
Date of last prostate exam? 1 year ago
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

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

Other:

Other:

Other:

General Constitution
Recent weight loss
How many lbs? 70
Time frame? 1 year
Intentional? Yes
How do you view your overall health? Good until now with the cancer.

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.

University of South Florida College of Nursing Revision September 2014

10

10 PHYSICAL EXAMINATION:
General Survey: Patient
Height 69 inches
Weight: 175.1 lbs.
BMI: 25.91
Pain: (include rating and
states a pain of 2 from
location): Slight pain in
Pulse: 74
Blood Pressure: (include location):
his RUQ that results
RUQ, rates at a 2.
131/84
right
arm.
Respirations: 18
from his recent
procedure, it is a dull and
reoccurring pain that gets
better with pain
medication and rest.
Temperature: (route
SpO2: 97%
Is the patient on Room Air: RA
taken?) 98.8, oral
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): Patient has a slight rash in groin area.
Central access device Type: Peripheral IV, heplock
Location: upper forearm
Date inserted: 10/25/16
Fluids infusing?
no
yes - what? Piperacillin/tazobactum 4.5 in 100mL, Q8H infused over 240 mintues
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 / 2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear4 inches & left ear- 4 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 clear
LUL clear
RML clear
LLL clear

Chest expansion

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11

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

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)
n/a

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: 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 10 / 24 / 16 )
Semi-formed
Color: Light brown
Nausea
emesis Describe if present: patient complains of feeling a little nauseous
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe:
GU
Urine output:
Clear
Cloudy
Color:
clear yellow Previous 24 hour output:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness

950 mLs

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:

Brachioradial: 2

Patellar:2

Achilles:2

Ankle clonus: negative Babinski: negative

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12

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
Na: 136

Dates
(10/25/16)

132

(10/27/16)

(Normal limits:136-145)

K+: 4.0

(10/25/16)

3.8

(10/27/16)

(Normal limits: 3.5-5.2)

Glucose: 91

(10/25/16)

127

(10/27/16)

(Normal limits: 65-110)

Trend
The patients sodium
started very low on the
normal range scale and it
has continued to decrease
within a two day span.

Potassium levels are

within normal levels for
the patient in a two-day
span. They did decrease
by .2, but nothing drastic.

Glucose levels were

within normal limits, but
increased dramatically in
the two-day span, nurse
needs to check why they
have suddenly elevated.

Analysis
Na is an essential
electrolyte that helps
maintain the balance of
water in and around the
cells. It is important for
proper muscle and nerve
function. Causes for low
sodium levels could
include- severe vomiting
and diarrhea, certain
medications such as
diuretics, drinking too
much water, liver disease
or heart disease. These
levels should be closely
monitored on this patient
to make sure they stay
within the normal limits.
Potassium is the
electrolyte mostly
concentrated inside the
cells of the body. It is
essential for conducting
nerve impulses and
muscle contractions.
Levels are within normal
range of the patient
Frequent or ongoing high
blood sugar can cause
damaged to nerves, blood
vessels and organs.
Causes of high blood
sugar include: skipping or
forgetting insulin, eating
too many grams of
carbohydrates, infection,
stress or an illness. In this
case the elevated blood

University of South Florida College of Nursing Revision September 2014

13

WBC: 14.14

(10/25/16)

10.80

(10/27/16)

(Normal limits: 3.9-9.9)

RBC: 4.1

(10/25/16)

3.8

(10/27/16)

(Normal limits: 4.1-5.7)

The patient arrived at the

ED with a very elevated
WBC count due to
infection, which
correlated with the fever
of 101.4. The patient was
on antibiotics and the
WBC count has slowly
been decreasing and
almost at the normal
limit.

The RBC is within

normal limits, but more
towards the lower side.
This should be something
that should be closely
monitored.

glucose levels may be

increased due to the
patient fighting off an
infection.
WBC count indicated an
overall increase or
decrease in the number of
white blood cells. A high
WBC count usually
indicates some sort of
infection, inflammation,
or leukemia. The patient
came in with a fever and
chills and elevated WBC
so it was evident he was
fighting of an infection.
Now with the antibiotics,
the WBC has decreased.
RBCs circulate in the
blood and carry oxygen
throughout the body.
Some cases of low RBC
count include hemolytic
anemia, sudden or
chronic bleeding from the
digestive tract, bone
marrow damage, B12
deficiency, or kidney
failure. RBC count keeps
lowering meaning patient
might have one of those
problems states above.

+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 closely being monitored for his
fever and high WBC count. Antibiotics (piperacillin/tazobactam) are still being infused IV piggyback and patients
fever has also decreased since admission. Doctor aims to place patient on oral antibiotics and see if his WBC
count still remains within normal limits. Patients wound from whipple procedure is intact and no redness,
inflammation or pain noted. Doctor doesnt believe infection was due to the whipple procedure, but wants to keep
patient at least two more days to make sure no more symptoms arise. Patient is experiencing acute pain still for
the procedure and his limited on certain activities he can do.

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

1. Ineffective protection related to inadequate nutrition, abnormal blood profiles, drug therapies, and treatments.

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2. Ineffective health maintenance related to deficient knowledge regarding prescribed treatment

3. Situational low self-esteem related to diagnosis of cancer.
4. Risk for infection related to invasive procedure, pain and location of incision.
5.

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 15 CARE PLAN
Nursing Diagnosis: Ineffective protection related to inadequate nutrition, abnormal blood profiles, drug therapies and treatments
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will remain free from
Nurse will observe patients
Nutrient status is an important
Patient is reporting feeling a lot
infection (long-term goal)
nutritional status and help improve factor contributing to immune
better and wanting to go home 3
it if needed. Nurse will also make
competence and under nutrition
days after admission.
sure patient is using hand hygiene
impairs the immune system.
and taking preventative measures
to avoid infection.
Patient will explain precautions to
The nurse will educate the patient
Educating the patient on infection
Patient demonstrated what
take to prevent infection.
on what to do to prevent infection
and how to prevent them is a
precautions to take against
and keep surgical wound clean and crucial part in order to prevent
infection before discharge
free from infection
readmissions.
Patient will have normal
The nurse ill take the patients
Changes in vital signs can indicate Patients temperature has now
temperature before discharge.
temperature, pulse, and blood
the onset of bleeding and infection. decreased to 98.8 and all other vital
pressure every 2 hours while
The temperature in this case is very signs are within normal limits.
hospitalized.
important to monitor since the
patient came in with a temperature
of 101.4.
Patient will have WBC count
Nurse will administer antibiotic IV An elevated WBC count indicates
Patients WBC count went from
within normal limits in the next
piggyback Q8H to monitor
infection, so seeing if it lowers
14.4 on admission to 10.9.
two days.
elevated WBC.
with antibiotics is crucial to kill the
infection.

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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 * patient has durable medical needs, just needs to be monitored regularly so cancer doesnt reappear.
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: Situational low self-esteem related to diagnosis of cancer.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will demonstrate improved Assist client with evaluating the
Nurses are encouraged to assist
Patient states he doesnt feel like
ability to interact with others in a
effects of family and peer group on their patients in strengthening their socializing anymore and wants to
social setting.
feelings of self-worth.
relationships with their family and focus on his health as long as
peers.
work on bringing his family
together
Patient will identify personal
Nurse will actively listen to and
Listening and nurturing patients are Patient states he plans on getting
strengths, accomplishments and
respect the client.
important aspects of care.
better and making sure the cancer
values before discharged
never returns and he doesnt get
another infection.
Patient will work on small
Nurse will assess existing strengths Supporting a clients beliefs and
Patient plans to lose more weight
achievable goals for the next year.
and coping abilities and provide
self-reflection and helping them
and get involved more in the
(long-term goal)
opportunities for their expression
cope can help their self-esteem.
community.
and recognition.
Patient will also improve
Nurse will encourage independent
Decision-making is essential to a
Patient is still making inpendent
independent decision-making.
decision making by reviewing
sense of autonomy for the patient.
decisions and his recent diagnosis
options and their possible
was a wake up call that he needs
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consequences with client.

to get out more and enjoy life.

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
Patient is ready to be discharged back home to his wife whenever the doctor takes him off the antibiotic.

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References
Cherry, Kendra (2015, December 26), Integrity Versus Despair. Retrieved from:
http://psychology.about.com/od/psychosocialtheories/a/integrity-versus-despair.htm

Fernandez-Cruz L. Periampullary carcinoma. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment:
Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK6924/

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