UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Brian Poirier

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION
Patient Initials:
Gender:

A.W.

Male

Assignment Date: 11/05/2013

Agency: Bayfront

Age: 40

Admission Date: 10/30/2013

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Anal Cancer: C18.9

Level of Education: High School Diploma, some college courses.

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired on disability, Mortgage

banking background.
Number/ages children/siblings: Sister-48 years old

Served/Veteran: No

Code Status: DNR

Living Arrangements: Owns an apartment on the first floor with no

stairs, mother lives with him to serve as caregiver.

Advanced Directives: Living Will

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

Culture/ Ethnicity /Nationality: Caucasian/ Non-Hispanic

Religion: Christian

Type of Insurance: Medicaid Medicare

1 CHIEF COMPLAINT: Severe pain and discomfort.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient was diagnosed with anal cancer three years ago. the patient had a bloody bowel movement and afterwards
scheduled a colonoscopy where cancerous growths were found. Patient reported no pain associated with growths, only a
bloody bowel movement. Patient started chemotherapy and radiation shortly after and was in remission after tumors and
growths were not found again. One year ago masses were found again. On 10/31/13 the patient called his primary care
physician due to vomiting, increased pain and discomfort related to his cancer and an abscess that had developed in his
groin, requesting to be admitted to hospice; he was evaluated and was admitted on 10/30/13. The patient had decided to
stop chemotherapy treatments on 10/29/13.

University of South Florida College of Nursing Revision August 2013

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

Father

62

Mother

76

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
)
Cirrhosis

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
broken finger
Colostomy and suprapubic catheter placement
Left and Right Nephrostomy tubes placed
Anal Cancer
Asthma
Hyperlipidemia
Vein filter placement for DVTs. Patient was unsure of type of filter and location.
Schizoaffective disorder and major depression
Hemorrhoid surgery

Age (in years)

Date
2009
2/2013
10/2013
2010
1979
1993
2013
2006
Unknown by
patient

Brother
Sister

48

relationship
relationship
relationship

Comments: Include date of onset

Patients father was an alcoholic for as long as he could remember. Lung and throat cancer was prevalent on fathers side of the
family.

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 (Within last 5 years)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)

YES

University of South Florida College of Nursing Revision August 2013

NO

Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Medications

Pollen

Rhinorrhea, watery eyes.

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)
According to the American Cancer Society: Most anal cancers in the United States are squamous cell carcinomas. These
tumors come from the squamous cells that line the anal margin and most of the anal canal (What is anal cancer?. 2013).
Generally (but not universally) squamous cell carcinomas are formed by healthy squamous cells, such as skin cells, being
exposed to ultra violet radiation via sunlight. When healthy cells are exposed to an environmental carcinogen DNA
damage occurs in the cell, which will repair the DNA or die. Some cells do not die and are unable to repair the DNA,
resulting in replicated cells with mutations. These mutations can affect the growth and function of a cell and after several
rounds of replication the result may be a cancer cell that has uncontrolled or limitless replication. This cell will produce
daughter cells that will also have uncontrolled growth and as a group will begin to invade surrounding tissues altering
tissue and eventually organ function (What is cancer?. 2013). The American Cancer Society states Most squamous cell
anal cancers seem to be linked to infection by the human papilloma virus (HPV), the same virus that causes cervical
cancer (What are the risk factors?. 2013). Individuals who engage in repetitive anal intercourse and those with HIV or
AIDS are also at an increased risk for anal cancer (What are the risk factors?. 2013). Anal cancer can be diagnosed by a
colonoscopy. Anal cancer has a 5 year survival rate of 64% when graded a stage 2 or less, stage 3 and above stagings fall
below 50% (Survival by stage. 2013). Individuals with hereditary autoimmune disorders may be placed at a greater risk
for anal cancer.

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

Concentration (mg/ml)

Route P.O.

Dosage Amount (mg) 400mg

Frequency bid

Pharmaceutical class integrase strand transfer inhibitors

Home

Hospital

or

Both

Indication: HIV-1 infection (with other antiretrovirals) in treatment-experienced or treatment-nave patients.

Side effects: Suicidal thoughts, headaches, depression, dizziness, fatigue, weakness, myocardial infarction, diarrhea, abdominal pain, gastritis, hepatitis,
vomiting, renal failure/impairment, anemia, neutropenia, lipodystrophys, hypersensitivity reactions, immune reconstitution syndrome, fever.
Nursing considerations: Monitor for anxiety and depression, assess for suicidal thoughts and depression. Educate patient that the drug does not cure AIDS and
they are still infectious. Educate patient on importance of compliance and taking the drug as scheduled. Monitor patient for CD4 counts and anemia. Educate
on signs and symptoms of immune reconstitution.
Name Epzicom (abacavir and lamivudine)

Concentration

Dosage Amount: 600 mg abacavir and 300mg

lamivudine

Route P.O.

Frequency Daily

Pharmaceutical class: Nucleoside reverse transcriptase inhibitor

Home

Hospital

or

Both

Indication: Management of HIV infection (AIDS) in combination with other antiretrovirals.

University of South Florida College of Nursing Revision August 2013

Side effects: Headache, insomnia, myocardial infarction, hepatomegaly, diarrhea, nausea, vomiting, anorexia, rashes, lactic acidosis, hypersensitivity reactions,
fat redistribution, immune reconstitution syndrome.
Nursing considerations: Monitor for lactic acidosis and hepatomegaly. Educate patient that the drug does not cure AIDS and they are still infectious. Educate
patient on importance of compliance and taking the drug as scheduled. Assess heart health before administration and educate patient on risks for myocardial
infarctions/ signs and symptoms. Educate on signs and symptoms of immune reconstitution.
Name Advair (fluticasone and salmeterol)

Concentration

Dosage Amount: 100 mcg fluticasone and 50

mcg salmeterol (chart says one puff BID)

Route inhaled

Frequency bid

Pharmaceutical class: corticosteroids

Home

Hospital

or

Both

Indication: Maintenance and prophylactic treatment of asthma. May decrease requirement for or avoid use of systemic corticosteroids and delay pulmonary
damage that occurs from chronic asthma.
Side effects: headaches, dizziness, dysphonia, hoarseness, oropharyngeal fungal infections, nasal stuffiness, rhinorrhea, sinusitis, bronchospasm, cough, upper
respiratory tract infection, wheezing, diarrhea, adrenal suppression, decreased bone mineral density, decreased growth in children, Cushings syndrome, muscle
pain, hypersensitivity reactions, laryngeal edema, urticarial, Churg-Strauss Syndrome.
/Nursing considerations: Educate patient on Churg Strauss signs and symptoms, educate patient on emergency procedures associated with hypersensitivity
reactions and laryngeal edema. DO NOT stop taking suddenly with chronic use to reduce complication from adrenal insufficiency,
Name Fenofibrate
Concentration
Dosage Amount 130 mg
Route P.O.

Frequency Daily

Pharmaceutical class: Fibric acid derivatives

Home

Hospital

or

Both

Indication: With dietary therapy to decrease LDL cholesterol, total cholesterol, triglycerides, and apolipoprotein B in adult patients with hypercholesterolemia
or mixed dyslipidemia.
Side effects: Pulmonary embolism, arrhythmias, deep vein thrombosis, cholelithiasis, pancreatitis, rash, urticarial, rhabdomyolysis, hypersensitivity reactions.
/Nursing considerations: Obtain a diet history (specifically fat consumption) before administration, monitor triglyceride and cholesterol levels, and educate
patients on signs and symptoms of pulmonary embolism and deep vein thrombosis.
Name Methadone

Concentration

Dosage Amount 10 mg

Route P.O.

Frequency Q 8H, around the clock

Pharmaceutical class: Opioid agonists

Home

Hospital

or

Both

Indication: Severe pain, suppresses withdrawal symptoms in opioid detoxification

Side effects: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis,
respiratory depression, torsades de pointes, hypotension, bradycardia, QT interval prolongation, constipation, nausea, vomiting, urinary retention, flushing,
sweating, physical dependence, psychological dependence, tolerance.
Nursing considerations: Clarify all ambiguous orders before administration, have second practitioner independently check original order and dose. Monitor for
constipation, hypotension, depressed respirations, and cardiac arrest. Use in extreme caution with MAOIs. Assess pain levels BP, pulse and respirations before
administration and monitor BP, pulse and respirations during drug schedule. Assess for dependence and addiction. educate patient on signs and symptoms of
torsades de pointes, also assess for constipation during drug treatment.
Name Dilaudid

Concentration

Dosage: 1.5 mg every hour with 0.5 mg Q 10

minutes PRN
Frequency: 1.5 mg every hour with 0.5 mg Q 10 minutes PRN

Route: Port PCA pump

Pharmaceutical class: Opioid agonist

Home

Hospital

or

Both

Indication: Moderate to severe pain ( alone and in combination with nonopioid analgesics), extended release product for opioid-tolerant patients requiring ATC
management of persistent pain, antitussive (lower doses).
Side effects: : Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred vision, diplopia, miosis,
respiratory depression, hypotension, bradycardia, , constipation, nausea, vomiting, urinary retention, flushing, sweating, physical dependence, psychological
dependence, tolerance.
Nursing considerations: Clarify all ambiguous orders before administration, have second practitioner independently check original order and dose. Monitor for
constipation, hypotension, depressed respirations, and cardiac arrest. Use in extreme caution with MAOIs. Assess pain levels, BP, pulse and respirations before
administration and monitor pain levels, BP, pulse and respirations during drug schedule. Assess for dependence and addiction. Also assess for constipation
during drug treatment.
Name Keflex

Concentration

Dosage Amount 500 mg

Route P.O.

Frequency TID for 14 days

Pharmaceutical class: first generation cephalosporins

Home

Hospital

or

Both

Indication: Treatment of the following infections caused by susceptible organisms: skin and skin structure infections, respiratory tract infections, otitis media,
UTIS, and bone infections.
Side effects: Seizures, pseudomembranous colitis, vomiting, abdominal pain, nausea, diarrhea, rashes, urticarial, eosinophilia, hemolytic anemia, neutropenia,
thrombocytopenia, anaphylaxis, super infection.
Nursing considerations: Take Cephalosporins at least 1 hour before or 4 hours after iron or antacid, rashes may appear several days after administration
assess integumentary system before and after administrationpeople allergic to penicillin may be allergic to cephalosporins. Educate patient on importance of
taking full dose of antibiotic even if symptoms disappear, educate on pseudomembranous colitis signs and symptoms and educate about super infections.
Name Ativan

Concentration

Dosage Amount 0.5mg

University of South Florida College of Nursing Revision August 2013

Route P.O.

Frequency Q 4 H, PRN

Pharmaceutical class: Benzodiazepine

Home

Hospital

or

Both

Indication: Anxiety disorder, preoperative sedation, decrease preoperative anxiety and provides amnesia, antiemetic prior to chemotherapy, insomnia, panic
disorder, as an adjunct with acute mania or acute psychosis.
Side effects: Dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, forgetfulness, confusion, mental depression, rhythmic myoclonic
jerking in pre-term infants, paradoxical excitation, blurred vision, respiratory depression, apnea, cardiac arrest, bradycardia, hypotension, constipation,
diarrhea, nausea, vomiting, weight gain, rashes, physical dependence and psychological dependence.
Nursing considerations: Do not take with alcohol or other CNS depressants, do not take with MAOIs, smoking may decrease effectiveness, and chamomile and
kava-kava can increase CNS depression. Use for short term and treat underlying problem when used as antianxiety, avoid driving/operating heavy machinery
until response to medication is known.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 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 pt follows at home? None
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1 bowl of whole grain cereal with cup skim
One bowl of whole grain (~ 1 cup) cereal is a great start,
milk with 8 oz. Orange Juice and 8 oz. coffee with 2 tsp.
but only accounts for 1oz of the total recommended amount
cream and 2 tsp. sugar. Sometimes oatmeal.
of 7 oz. A better option for breakfast would be one cup of
oatmeal which would provide 2 oz. of whole grains. The
patient should continue to drink a glass of OJ every
morning; one cup of OJ is equal to 1 cup of fresh fruit and
is half the recommended value for 31-50 year old males.
Oatmeal can also act to reduce cholesterol levels.
Lunch: Fish (about 4 oz.) and seafood, fried mostly but
grilled, blackened or baked depending on seafood. 1-1/2
cup coleslaw, French fries or hushpuppies and 16 oz. of
sweet tea, soda or water.

Fish is a great source of lean animal protein and healthy

fats. I small filet of trout is equal to about 3 oz., or half the
recommended daily amount. The patient reported fried fish
being his favorite preparation of seafood which
unfortunately is the unhealthiest preparation. Cole slaw,
which can contain copious amounts of fattening
mayonnaise, hush puppies and French fries are not healthy
choices. Fried and fatty foods should be avoided because
they may increase GI discomfort in patients who are taking
nucleoside reverse transcriptase inhibitors such as Epzicom.

Dinner: Tries to cook fish or chicken mostly, mother makes

German food (Wiener Schnitzel, sour kraut dishes)
frequently, infrequently has vegetables when vegetables are
cooked they consist of a salad with vinegar and oil or
steamed vegetables with cheeses sauce (1/2 cup). Also
drinks 1-2 glasses of sweet tea with dinner.

Fish and chicken are great sources of lean protein,

depending on their preparation. The patient does consume
healthy vegetables, but should consider removing cheesy
sauces from their preparation to potentially decrease
sodium intake. Sweet tea for lunch OR dinner may be
acceptable but should not be included in 2 of 3 daily meals.

Snacks: 3-4 slices of deli turkey meat, chips, Snickers

candy bar or other general snack foods.

Deli slices are great for protein. substituting carrots or

another healthy vegetable would increase the patients daily
intake of fiber and recommended amount of vegetables.
Candy bars and potato chips on a daily basis should be
avoided.

Liquids (include alcohol): Water, soda, sweet tea, OJ

usually daily.

Replacing sugary drinks such as sweet tea and soda with

water would be an excellent way to cut excess
carbohydrates.
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 reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patients mother acts as caretaker and lives with him.

University of South Florida College of Nursing Revision August 2013

How do you generally cope with stress? or What do you do when you are upset?
The patient will go on a walk outside to relieve stress. The patient grew up surfing but can no longer surf due to recent
health deterioration. He plans on continuing to walk or use his wheel chair in the future.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient has a fear of the unknown or whats next in his 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? ___________No_____________________________________
Have you ever been talked down to?__yes_____________ Have you ever been hit punched or slapped? ____yes_____
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______yes_______________________ If yes, have you sought help for this? yes, after an incident when he was
younger he saw a caseworker to help him through his relationship.
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: Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of
wisdom, while failure results in regret, bitterness, and despair (Erikson's Stages of Psychosocial Development. 2013).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: The patient

was in a stage of despair in ego-integrity vs. despair. Although the patient was only middle aged the diagnoses of aids and
terminal cancer have accelerated his psychosocial development. The patient commented several times that he was in
disbelief about his conditions and lamented the actions in his youth. in Eriksons staging, someone who looks reflects on
their life and is not fulfilled results in regret, bitterness, and despair (Erikson's Stages of Psychosocial Development.
2013); exactly what the patient was verbalizing.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patients terminal diagnoses have accelerated his developmental stage, instead of generativity vs. stagnation where a
middle aged individual would normally be, the patient is now forced to reflect and review the actions in his life to assess
whether he will leave a positive or negative effect on his close relations. The patient acquired HIV through his actions as a
young adult and feels that he wasted his life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? HIV The patient believes the cause of his illnesses are due to
complications from HIV.

University of South Florida College of Nursing Revision August 2013

What does your illness mean to you? Still working on an answer to that. The patient is anxious about the afterlife
whether it will be a negative or positive existence. The patient had difficulty answering this question and varied day to day
on his interpretations of the illness.

+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? ___Other than HIV, no._________________
Have you or a partner ever had an abnormal pap smear?____N/A____________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ____________N/A_________________________
Are you currently sexually active? ____No__________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __________________________________
How long have you been with your current partner?______None__________________________________________
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 August 2013

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

What importance does religion or spirituality have in your life? Strong personal spirituality, does not go to church regularly but his
beliefs can be a source of strength
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? The patient sometimes believes that his illnesses are a punishment for his
past actions, but generally his beliefs are a source of strength for him
______________________________________________________________________________________________________
______________________________________________________________________________________________________

+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)
Cigarettes
pack a day (20 cigarettes)

Yes
No
For how many years? 4 years
(age 36

thru

40

If applicable, when did the

patient quit? 6 months ago

Pack Years: 4
Does anyone in the patients household smoke tobacco? If
so, what, and how much? no

Has the patient ever tried to quit? yes, started 6 months

ago

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
10 beers/5 liquor drinks (mixed with
Beer and Liquor
soda). whatever it took to get
blackout drunk

For how many years? 22 years

(age

17 thru

39

If applicable, when did the patient quit?

Has only quit within the last 6 months to a year, has tried to quit since his first hangover. Had several relapses and has
battled with quitting.
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Ecstasy, cocaine and marijuana and steroids.
How much?
For how many years? 6-7 years
Ecstasy: Weekend use-3 days
every week patient would take
a pill of ecstasy (unknown
amount) every four hours.
Cocaine: Unknown amount
every weekend starting at age
(age 18 thru 25
)
18 for 4-5 years.
Marijuana: Joints on occasion
or whenever available.
Steroids: used Sustanon for 5
years (20-25). 1cc 5 days a
week.
experimented with drugs when 18-19
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No
25
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks: No

University of South Florida College of Nursing Revision August 2013

University of South Florida College of Nursing Revision August 2013

10

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections: abscess
Use of sunscreen none
SPF:
Bathing routine: sponge bath daily/every
other day
Other:

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
1/day
Routine dentist visits
2/year
Vision screening
Other: Current illness is affecting his oral

Gastrointestinal

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction

Appendicitis

Enlarged lymph nodes

Abdominal Abscess
Last colonoscopy: 3 years ago, found
disease.
Other:

Other:

Genitourinary

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

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
x/day
Bladder or kidney infections
Has nephrostomy tubes, does not urinate.

Cardiovascular
Hypertension
Hyperlipidemia: takes Antara
Chest pain / Angina
Myocardial Infarction
CAD/PVD

Metabolic/Endocrine

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam: early 20s
BPH
Urinary Retention

CHF
Murmur
Thrombus: has vein filter
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when: 1 month

Hematologic/Oncologic

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

care habits
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma: diagnosed at age 16
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies: pollen
last CXR: within last year
Other: Smoking aggravated asthma

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other: Diagnosed later in life but felt
affected as a child.

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox: as a child

University of South Florida College of Nursing Revision August 2013

11

ago
Other:

Other:

Other:

REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
Pts perception of health: Patient was very aware of deteriorating health and showed emotional, psychological signs of ineffective
coping mechanisms with hi diagnosis and condition. The patient recently lost 10lbs in one week from vomiting and inability to eat due
to nausea. He believes his chemotherapy treatment was the source of his nausea and vomiting.

Integumentary: Abscess in right groin area. ^6 months ago patient noticed blood dripping from his groin on the
way to a Dr. appointment. After a trip to the ER a CAT scan found an abscess in his groin. Antibiotics were
prescribed and the wound is bandaged and changed daily.
HEENT: The patient has environmental allergies (pollen) that result in general allergic symptoms: rhinitis and
watery eyes. The patient takes Claritin PRN for treatment. The patient had a motorcycle accident at age 14 and
lost his two front teeth. A bridge was inserted but a new bridge was necessary when the patient was in his 20s
due to a rotting tooth, pain prompted him to visit the dentist where the rot was discovered and a new bridge
placed. The patient recently accidentally threw out another bridge and is in need of another bridge. The patient
regularly visits a dentist and brushes his teeth but finds that pain and lethargy from his cancer is affecting his
oral care- feels too tired to brush teeth some days.
Pulmonary:
Cardiovascular: Diagnosed with genetic hyperlipidemia in his 20s and is prescribed Antara and has not adjusted
his diet. Within the last 6 months he noticed swelling in his legs and went to his primary care physician where it
was determined that he had DVTs (patient unaware of type of filter, number of filters or location) and venous
filters were placed in his legs.
GI: Last bowel movement 3-4 days ago. The patient used mirolax to address constipation before. The patient
now tries to increase his fluid intake amount as well as increase his intake of fiber to relieve constipation. 3
years ago the patient reported a bloody bowel movement which led to a colonoscopy and the discovery of anal
cancer, the patient has not reported a bloody bowel movement since then. The patient has had hemorrhoids
throughout his life and used OTC creams for treatment before having surgery once to correct.
GU: While during his last hospital stay (w/in last few months, patient cannot recall when), it was noticed that his
urine was cloudy, a C+S was performed and he was diagnosed with a UTI and prescribed antibiotics.
Women/Men Only: Patient reported Chlamydia in his early 20s. Patient noticed discharge coming from meatus
of penis and sought attention from his primary care physician, antibiotics were prescribed for treatment.
Musculoskeletal:

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Immunologic: Patient has been diagnosed with HIV and frequently has night sweats, patient attempts to adjust
room temperature to keep cool but reports that the night sweats cannot be alleviated. The patient is currently
prescribed Isentress and Epzicom for management of HIV symptoms.
Hematologic/Oncologic: The patient is anemic- was borderline for a while now but was diagnosed within the
last year. The patient reports he takes no medications for his anemia. The patient has also had 5 transfusions in
the last year carried out at various hospitals. The patient was also diagnosed with anal cancer 3 years ago and
underwent chemotherapy treatment but has ended the treatment as of 10/29/2013.
Metabolic/Endocrine:
Central Nervous System: The patient reports experiencing migraines from a young age (childhood) and does not
take medication to relieve symptoms. The patient alleviates symptoms by sitting in a dark place or sometimes
induces vomiting, which the patient states reduces pain and helps migraine episodes pass. The patient also
reports ticks and tremors of the upper extremities which he believes his bipolar and schizoaffective disorders are
the underlying cause (diagnosed at age 33-34 and medicated).
Mental Illness: The patient was diagnosed with major depression, schizoaffective disorder and bipolar disorder
around age 33-34. The patient believes he has suffered from these mental ailments since a young child stating
that he was affected as a child. The patient is prescribed, Ativan and Depakote for treatment and in past has
taken Abilify and Lithium (did not know when he stopped taking).
Childhood Diseases: Contracted chicken pox as a child (patient unsure of age).

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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10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is a
Height: 68
Weight 199
BMI: 30.3
Pain: (include rating & location)
8/10, location in groin R/T abscess and
well-kept 40 year old
Pulse: 98
Blood
generalized over body due to cancer and
Caucasian male appearing
Pressure: 126/90
recently placed nephrostomy tubes.
(include location)
younger than stated age. The
patient did not complain of
pain but presented signs of
continuous pain throughout
interview-grimacing, pacing,
ambulating cautiously and
using his PCA pump multiple
times per hour.
Temperature: (route taken?)
Respirations: 20
SpO2: Hospice doesnt take
Is the patient on Room Air or O2:
96.6 oral.
this vital and we could not
locate in chart
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
apathetic
bizarre
agitated
anxious
tearful
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

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type:

Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type: Port
Location: Left Chest slightly lateral of mid clavicular line, superior
to nipple
Date inserted: 2010
Fluids infusing?
no
yes - what? Dilaudid
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

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Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3/3 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: Missing two front teeth, no problem with dentition.
Comments:

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15

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
CR - Crackles
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Sputum production: thick thin

Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5 intercostal space mid clavicular line.
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema:
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Left Knee
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
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
Urine output:
Clear
Cloudy
Color: Yellow/clear and brown/cloudy Previous 24 hour output: not recorded by
hospice/not in chart.
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 29 / 2013 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe: Urine from suprapubic catheter dark yellow/brown with cloudiness, urine from nephrostomies clear and
light yellow.

Musculoskeletal:
Full ROM intact in all extremities without crepitus
Strength bilaterally equal at __5___ RUE ___5_ LUE _______ RLE & _______ 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 parathesias
Did not assess patients lower extremity range of motion or strength due to risk of fall hazard of pain/weakness from
abscess, nephrostomy tubes/ bags and suprapubic tubes and bag.
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:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Did not fully assess, we had not learned this at the time of the PAT and we were also called in to help assess a new
admission and did not have time to complete.

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-11.2
Hgb-8.5
Hct-25.9
Platelet Count-531
Neutrophil absolute-8635
Monocyte absolute-1131

Dates
(10/31/2013)

Normal:
WBC-4.8-10.8
Hgb-14.0-18.0
Hct-42.0-52.0
Platelet Count-130-400
Neutrophil absolute1500-7000
Monocyte absolute-50600

GFR calculation (non African American)-47.68

Normal:
>=60

(10/31/2013)

Trend
The patients WBC were
in the high range,
hemoglobin levels were
in the low range,
hematocrit levels were in
the low range, platelet
count was high, absolute
neutrophil count was high
as well as the absolute
monocyte count.

The patients Glomerular

Filtration Rate was
calculated at 47.68, lower
than the reference value
of 60

Analysis
High WBCs, Neutrophils
and Monocytes indicate the
presence of an infection or
inflammation. The elevated
levels of WBCs
Neutrophils and Monocytes
could be due to the abscess
the patient currently has.
Platelet levels may be
elevated due to recent
insertions of bilateral
nephrostomies and a
suprapubic catheter.
Decreased levels of
hematocrit and hemoglobin
may be caused by decreased
kidney function and blood
loss associated with the
placement of
nephrostomies. The patient
is also anemic.
A GFR of less than 60 is
indicative of chronic renal
disease. The patient had two
nephrostomy tubes placed in
his kidneys to alleviate any
blockage and allow for
drainage

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

diagnostic tests, consults, accuchecks, etc. Also provide rationale and frequency if applicable.)
Regular diet ordered. Daily wound care, (L) groin cleanse, replace gauze and use ABD pad every day and PRN.
Change nephrostomy tube dressings every day and PRN. No scheduled orders concerning vitals, activity or any
scheduled diagnostic tests.

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

3.
4.
5.

1.

Risk for Infection related to HIV and abscess in Left groin.

2.

Disturbed Body Image related to suprapubic catheter an nephrostomy tubes placement.

 15 CARE PLAN
Patient Goals/Outcomes
Demonstrate adaptation to changes
in physical appearance or body
function as evidenced by
adjustment to lifestyle change
(Long Term)

Nursing Diagnosis: Disturbed Body Image (Ackley and Ladwig. 2011)

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Incorporate psychosocial questions Assessment of psychosocial issues
related to body image as part of
can help to identify clients at risk
nursing assessment to identify
for body image concerns as a result
clients at risk for body image
of a disfiguring condition
disturbance ( e.g., body builders;
cancer survivors; clients with
stomas/ostomies/colostomies or
other disfiguring conditions ).
Assess for possibility of muscle
dysmorphia (pathological
preoccupation with muscularity
and leaness; occurs more often in
males than females) and make
appropriate referrals.

This condition is often seen among

body builders or those in sports
that emphasize size and bulk and
will ikely continue to increase with
societal focus on body image.
Fluoxetine alone or in combination
with CBT may be an effective
treatment. (Ackley and Ladwig p.
173).
If the client is at risk for body
A favorable body image quality of
image disturbance, consider using a life was related to higher selftool such as the Body Image
esteem, optimism, and social
Quality of Life Inventory or Body
support in both sexes and less
Areas Satisfaction Scale which
eating disturbance among women
quantify both the positive and
(Ackley and Ladwig p. 173).
negative effects of body image on
ones psychosocial quality of life.
Identify and change irrational
beliefs and expectations regarding
body size or function

Acknowledge denial, anger, or

The influence of emotion focused
depression as normal feelings when coping (venting emotions and
adjusting to the changes in body
mental disengagement) on distress

Evaluation of Goal on Day care is

Provided
Questions related to body image
were incorporated in the patient
assessment, patient vocalized
concern and disbelief at state of
body, specifically with
nephrostomy tube and suprapubic
catheter. Patient did not
demonstrate adaptation to changes
in body image on day care was
provided.
Patient did not demonstrate
adaptation to changes in body
image on day care was provided.

Patient did not demonstrate

adaptation to changes in body
image on day care was provided.

Patient was allowed to express

concerns about body image during
assessment and interview

(Short term)

and lifestyle. However, allow client

to share emotions when they are
ready, rather than rushing them
Provide client with a list of
appropriate community resources
(e.g., Reach to Recovery, Ostomy
Association).

following disfiguring injury was

associated with less body image
disturbance.
Motivation, sharing of experiences,
camaraderie with and support from
peers, and knowledge of not being
alone have been identified as
advantages of group learning.

potentially decreasing perceived

body image disturbance.
Patient was not provided with
appropriate community resources.

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
*Palliative Care

 15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Patient Goals/Outcomes

Nursing Diagnosis:
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References

Evaluation of Interventions on
Day care is Provided

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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Erikson's Stages of Psychosocial Development. (2013). Retrieved from: http://psychology.about.com/library/bl_psychosocial_summary.htm
Survival by stage of anal cancer. 2013. Retrieved from: http://www.cancer.org/cancer/analcancer/detailedguide/anal-cancer-survival-rates
What is anal cancer?. 2013. Retrieved from: http://www.cancer.org/cancer/analcancer/detailedguide/anal-cancer-what-is-anal-cancer
What is cancer?. 2013. Retrieved from: http://www.cancer.org/cancer/analcancer/detailedguide/anal-cancer-what-is-cancer