UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Tatyana Boytsan

Assignment Date: 11/03/15
PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: SMH
Patient Initials: M.C. Age: 40 Admission Date: 10/31/15
Gender: Female Marital Status: Married Primary Medical Diagnosis with ICD-10 code:
Primary Language: English C71.9 (Malignant neoplasm affecting the brain)
Level of Education: University Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Currently staying at home, not None
retired
Number/ages children/siblings: 3 girls (2,5,10)

Served/Veteran: No Code Status: Full Code

Living Arrangements: With husband and children. Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: 11/4/15 Procedure: Scheduled
resection of mass
Culture/ Ethnicity /Nationality: White
Religion: Christian Type of Insurance: Self-pay

1 CHIEF COMPLAINT:
Patient came in with the complaint of severe nonresolving headaches that had become more frequent and more severe
throughout the past week.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)

Patient has been having headaches for the past month. She came in with complaints of severe headaches that were
nonresolving which were progressively getting worse and more frequent within the past week. The headache is mostly one
sided (on the right) and the patient describes it as radiating from the occipital area toward the upper and frontal part of her
head. She denies any nausea, vomiting, visual disturbances, or aura. A CT scan was done upon admission that shows a
large mass in the right anterior frontal lobe which measures around 4.9cm with marked vasogenic edema and midline shift
of 1.4cm. There is no transtentorial herniation identified. Right frontal mass believed to possibly be glioblastoma or
metastatic tumor.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date Operation or Illness
2005 Diagnosed with Hashimoto thyroiditis (autoimmune disease)
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
of

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father 67
Mother 63
Brother
Sister
relationship

relationship

relationship

Comments: Include date of onset

Mother had Hashimotos thyroiditis

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date - doesnt remember)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date - doesnt remember)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
NONE

Medications

NONE
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)
The patient has a brain neoplasm. A neoplasm is when there is abnormal and new tissue growth on some part of the body,
in this case the brain, and it is usually characteristic of cancer. Manifestations (signs and symptoms) may be nonspecific
and insidious, including headaches, altered mental status, ataxia, nausea, vomiting, weakness, and gait disturbance. (Lo,
2015) When it comes to the headaches, location is important. Wherever the headache is located is a reliable source that
indicates which side of the head has been affected, however it does not show the exact site of the tumor itself. (Lo, 2015)
Diagnosis is subjective and objective, where the patients symptoms lead up to the diagnosis. Laboratory tests like CBCs
(complete blood counts), coagulation studies, and neuroimaging such as a CT scan, are all ways to diagnosis. (Lo, 2015)
Once diagnosed, treatment is different for everyone depending on the finding. Treatment will be planned in an
interdisciplinary way, and may include surgical options like tumor removal.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name Cefazolin (Kefzol, Ancef) Concentration (mg/ml) 2mg Dosage Amount (mg)

Route IVPB Frequency once

Pharmaceutical class first generation cephalosporin Home Hospital or Both
Indication PRE-OP to decrease risk of infection, essentially perioperative prophylaxis.
Side effects/Nursing considerations s/e include diarrhea, nausea, vomiting, rash, and possible phlebitis of the IV site.

Name Dexamethasone Concentration 4mg Dosage Amount

Route IV PUSH Frequency Q6 hour

Pharmaceutical class steroid/anti-inflammatory Home Hospital or Both
Indication Used systemically and locally in inflammatory and neoplastic diseases by suppressing inflammatory response.
Side effects/Nursing considerations: Avoid chronic use. May cause many s/e including CNS depression, euphoria, hypertension, acne, petechiae, adrenal
suppression, and cushingoid appearance.
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Name Famotidine (Pepcid) Concentration Dosage Amount 20 mg

Route ORAL Frequency BID

Pharmaceutical class Histamine H2 Antagonist Home Hospital or Both
Indication Prevention of stress ulceration.
Side effects/Nursing considerations Common side effect is confusion. Adverse effects include arrhythmias, agranulocytosis, and aplastic anemia (which the nurse
should be aware of the signs for). Administer with meals, or immediately after, and at bedtime for a prolonged effect.
Name Levetiracetam (Keppra) Concentration Dosage Amount 500mg

Route ORAL Frequency BID

Pharmaceutical class Pyrrolidines Home Hospital or Both
Indication For seizures, used to decrease incidence and severity of seizures.
Side effects/Nursing considerations May increase risk of suicidal ideation. Other side effects include aggression, agitation, anger, anxiety,depression, dizziness,
weakness, drowsiness, and coordination difficulties.

Name Magnesium malate Concentration Dosage Amount 200mg

Route ORAL Frequency ONCE DAILY

Pharmaceutical class Supplement Home Hospital or Both
Indication Can be taking for constipation, irregular heartbeats, dyspepsia, or magnesium deficiency.
Side effects/Nursing considerations High doeses should not be taken with people who have cardiac issues like a heart block or thin blood due to anticoagulants.

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Gluten free and lactose free Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Gluten free and lactose free Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Smoothie, an example would be a smoothie with
spinach, kale, strawberries, a banana, a kiwi, and cup of
almond milk.

Lunch: Hummus with gluten free flat bread, cup carrots,

and a few stalks of celery.

Dinner: Quinoa chili (with quinoa, a sweet potato, a red

pepper, black beans, and an onion)

Snacks: Generally doesnt snack, aside from the occasional

fruit or something.

Liquids (include alcohol): tea, pH balanced water, juiced

fruits and vegetables sometimes.

The patient follows her personal diet very well, and it seems
to work very well for her. She easily exceeds the minimum
amount of fruits and vegetables recommended daily, 113%
and 223% accordingly. She is below the amount of grains
recommended to eat, only at 60%, however her grain amount
varies day by day and on other days would meet the target.
She also does well with getting in meatless sources of protein!
Foods like black beans and quinoa are great sources of
protein. Otherwise, she is within average levels of everything
else. She doesnt exceed the recommended oil, saturated fat,
and sodium levels.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Patients husband and mother.
How do you generally cope with stress? or What do you do when you are upset?
Usually not too stressed or upset, but meditation helps a lot.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient has been feeling anxious over the mass and thoughts of what it could be, if it is serious, how it will affect her
and her family, etc.

+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__________________________________________

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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: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your patients age group:
Since the patient is 40 years old, this places her in middle adulthood where the psychosocial crisis is generativity vs self-
absorption. The developmental task for this stage is to fulfil life goals that involve family, career, and sociality;
developing concerns that embrace future generations (Halter, 2014). In generativity, the person has an ability to give and
to care for others around them. This could be related to friends and family, or people in general like the homeless or
refugees. On the other hand, self absorption is when the person is solely focused on themselves and their own wants and
need, with the inability to grow as a person and their lack of desire to set or work at goals for the future (Halter, 2014).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the Generativity stage. This is a time for settling down and achieving goals. She is satisfied with her
fulfilled family life goals, with her lovely husband and three wonderful children. She is raising the children, and says that
she is satisfied in the position in life that she is currently in.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
So far it has not had much of an affect on the patients developmental stage of life, as it has just been a sudden onset of the
situation. The headaches that have been leading up to the discovery of the neoplasm have not affected her outlook on life.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Im not sure to be honest.

What does your illness mean to you?

Right now the mass doesnt mean much as she is still trying to wrap her mind around what it could be. Right now is just a
suspension of time, it all depends on what it turns out to be which could change her life completely or just be a small deal.

+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

University of South Florida College of Nursing Revision August 2013 6

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? ______________YES_________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? ___________CONDOM_____________

How long have you been with your current partner?___________________13 years____________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ___________NO__________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
NO

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
________Spirituality is important, and a part of life!___________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_A little bit, the patient has met with the chaplain for some help with anxiety and accepting the current situation.________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much?(specify daily amount) For how many years? 2 years
Cigarettes Eventually up to of the pack. (age 1990 thru 1992 )

If applicable, when did the

Pack Years: ONE
patient quit?
1992
Does anyone in the patients household smoke tobacco? If
Has the patient ever tried to quit?
so, what, and how much?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? (give specific volume) For how many years?
(age thru )

If applicable, when did the patient quit?

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

Is the patient currently using these drugs?

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
NO

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 10 REVIEW OF SYSTEMS
General Constitution Gastrointestinal Immunologic
Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 30 Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 4 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
Routine dentist visits 3 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing (choose not to answer) Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety (at the moment/no dx)
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Arthritis Chicken Pox
Other: Other: Other:

University of South Florida College of Nursing Revision August 2013 9

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 August 2013 10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)
General Survey: Normal, aao Height: 55 Weight: 126ibs BMI: 21 Pain: (include rating & location)
x3 Pulse: 81 Blood 0/10
Temperature: (route taken?) Respirations: 18 Pressure: 120/79, left arm
(include location)
96.8F, oral
SpO2 97% Is the patient on Room Air or O2: room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

Peripheral IV site Type: 18 guage Location: left hand Date inserted: 11/02/15
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: Location: Date inserted:
Fluids infusing? no yes - what?

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 4 / 4 mm Peripheral vision intact EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013 11

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 Sputum production: thick thin Amount: scant small moderate large
CR - Crackles Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

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

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

GI/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 Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 11 / 3 / 2015 ) 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:
Musculoskeletal: X 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 parathesias

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: +2 Biceps: +2 Brachioradial: +2 Patellar: +2 Achilles: +2 Ankle clonus: positive negative Babinski: positive negative

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

Lab Dates Trend Analysis

Thyroid Stimulating Though it is low, no trend Produced by the pituitary
Hormone available, as blood was gland, TSH tells the
only drawn once. A low thyroid to make/release
0.101 10/31/15 [1038] TSH could be indicative hormones. The patients
of an underactive thyroid. lab value is likely related
Normal (0.358-3.740) to her Hashimotos
thyroiditis.
CT thorax, abdomen, 10/31/15 [1409] N/A Report came back
and pelvis with IV unremarkable, no issues.
contrast.
CT - Head 10/31/15 [0132] N/A Large mass found in right
anterior frontal lobe,
could be cancer (benign
or metastatic).
MRI of Brain 10/31/15 [1159] N/A Mass diagnosed to be
primary neoplasm (for
example, glioblastoma
multiforme) or metastatic
disease.

The patient has only been in the hospital a couple of days, however most blood work has only been done on
the first day of admission and has not been done again since then. This means that unfortunately there are
no trends to view.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Gluten free and lactose free diet is being followed, according to the usual diet of the patient. Vitals are
being done every four hours, and blood work has been done once upon admission. CT-thorax was negative.
CT of brain done upon admission sound large mass in right anterior frontal lobe measuring around 4.pcm
with marked vasogenic edema and midline shift to the left of 1.4cm.. No transtentorial herniation
identified. MRI with and without contrast was then done which found an intra-axial mass within the right
frontal lobe with extensive surrounding vasogenic edema. The mass measures about 3.5 x 2.5 x 3.0 cm.
Possibly diagnosis includes primary neoplasm. Awaiting orders for craniotomy to be scheduled on
11/04/15.

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

1. Anxiety related change in health status and unpredictability of outcome as evidenced by expressed concerns,
confusion, preoccupation and fear.

2. Deficient knowledge related to unfamiliarity with information as evidenced by patient report.

3. Chronic pain related to headaches as evidenced by facial grimacing, patient verbal self report, and complaints of
headache pain radiating from the occipital area toward the upper and frontal part of her head.

4.

5.
 15 CARE PLAN
Nursing Diagnosis: Anxiety related change in health status and unpredictability of outcome as evidenced by expressed concerns, confusion, preoccupation and
fear.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day care is
Goal Provide References Provided
Patient will feel less anxious this Encourage and support the patient Letting the patient know that she is Patient had low levels of anxiety
shift, and continue to have little to as much as possible, and supported (by the nurse and by her this shift.
no anxiety below a 4 on a 1 to 10 occasionally ask what level her family) assists with anxiety.
scale. anxiety is at. Providing physiological and social
support can reduce the symptoms
associated with anxiety (Ackley &
Ladwig,2014). Asking allows the
nurse to keep track of the anxiety.
Patient will find ways to cope with Patient education about different The best way to for the patient to The patient seemed accepting of
the situation she is going through. ways to cope with anxiety, from decrease her anxiety levels is to the information, and her EMR
meditation to having the chaplain know what helps decrease it. shows use of pastoral care.
come out and talk to the patient. Finding new ways, or reinventing
old ways, to deal with the anxiety
will decrease the
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
Nursing Diagnosis: Deficient knowledge related to unfamiliarity with information as evidenced by patient report.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Interventions on
Goal Provide References Day care is Provided
Figure out the patients ability and Simply speak to the patient and Knowing if the patient is able and Patient is capable and ready to
readiness to learn. find out if they can read or if they ready lets the nurse know that the learn more.
understand medical things, and if information will be getting
they are ready to learn about it or somewhere.
want to grieve for longer.
Set up best way for the patient to Use an individualized approach. Use whatever the patient prefers as
learn. Some patients prefer a lecture and this increases the patients
some prefer a brochure or print likelihood to retain the information. Patient had no preference but
outs that explain in laymens terms. Individualized education appreciated print outs.
interventions also have a positive
effect on clients and their outcomes
(Ackley & Ladwig,2014).
Teach about neoplasms, and the The nurse should prepare the The more the patient knows about Nurse provided teaching.
possible diagnoses the patient will simple information and some print what is going on, the more in
receive after the upcoming outs, and educate the patient. The control of the situation the patient
craniotomy. nurse may also call the doctor and feels which also decreased anxiety
see if he/she can educate the patient levels and helps the patient cope
on the illness in more depth, if the better.
patient desires such.
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
Nursing Diagnosis: Acute pain related to headaches as evidenced by facial grimacing, patient verbal self report, and complaints of headache pain radiating
Patient Goals/Outcomes
Patient will use a self report pain
tool, verbalizing a pain level less
than 4 on a scale of 1 to 10, 10
being the worst pain theyve ever
had.
Have the patient identify a comfort-
function goal, a pain level on the 1-10
scale that allows the patient to perform
ADLs or any activities with an easily
tolerable pain.
Learn how to control pain in a
nonpharmaceutical way, as as
assistance to the analgesic or as a
sole way of decreasing pain levels.
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
from the occipital area toward the upper and frontal part of her head.
Nursing Interventions to Achieve
Goal
Assess pain level as often as possible,
including when taking vitals and doing
assessments. If patient is experiencing
pain provide comfort measures, plus
nonpharmaceutical and
pharmaceutical ways (like
administering a prn pain medication)
of decreasing the pain level.
Speak to the patient and agree upon a
number that works best for them, and
then continue to work on keep their
pain level at or below that number.
Sit down and go over a list of
nonpharmaceutical ways of
controlling pain, possibly with a print
out for the patient to take home. These
include applying heat or ice to the
area, physical therapy, aromatherapy,
meditation, acupuncture, and more
Rationale for Interventions Evaluation of Interventions on
Provide References Day care is Provided
It is best to ask the patient if they are The patient suffered no headaches
having pain, as some patients may be this shift, and complained of little
shy and wont bring it up to you to no pain.
themselves. It is also important to
offer different options when it comes
to treating the pain, as not all patients
will want to take an analgesic.
Doing this allows for an The patient agreed with the
individualized pain management plan standard 4 on a scale of 1 to 10.
(Ackley & Ladwig, 2014) which
makes the care more patient focused
and interventions more successful.
Not all patients want to take analgesics. Patient was aware of
Others have a high tolerance and may nonpharmaceutical ways of dealing
need assistance in controlling their pain,
so nurses provide pharmaceutical and with pain, but was accepting of
continuing to learn.
nonpharmaceutical treatment options to be
used in conjunction.
 References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care

(10th ed.). Maryland Heights, Mo.: Elsevier.

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Halter, M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. (7th ed.).

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Lo, B. (2015). Brain Neoplasms. Retrieved November 20, 2015.

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http://nursing.unboundmedicine.com/nursingcentral/ub/