PFC Luna, Jose

68WM6 Program

DATA COLLECTION WORKSHEET

1. PSYCHOSOCIAL HISTORY
a) Age: 60
b) Gender: Male
c) Marital Status / Significant Others: Married
d) Primary Language: English
e) Religion: N/A
f) Barrier to Care: No impairment with sensory perception. Low fall risk. PT exhibits high
comprehension level, high knowledge level and high level of motivation to learn.
g) Other:
2. PAST MEDICAL HISTORY
a) Past Medical History: Back pain, arthritis of spine, hypercholesterema, mild eft sided
hearing loss.
b) Past Surgical History: Vastectomy 1986
c) Allergies: NKDA
d) Medications:
• Ibuprofen (Motrin)
600mg PO TID w/ meals
Nonopiod analgesic
Prevention/treatment of mild to moderate pain and inflammation. Given to patient to
decrease pain and inflammation related to surgery..
• Docusate sodium (Colace)
100mg PO BID
Laxative
Given to pt to avoid straining, also side effect of opioid analgesic is constipation.
• Bacitracin ( Bacitracin)
1 Dab TOP TID
Anti- infective
Pt taking a prophylaxis
 • Oxybutynin (Ditropan)
5mg PO QID PRN
Anitspasmodic
Helps pt w/ bladder spasms due to condition.
• Acetominophen/oxycodone (Percocet)
1-2 Tabs Q4 HRS
Pain reliever
Helps with breakthrough pain due to surgery.

e) Significant Family History: Non-Contributory

3. HOSPITALIZATION INFORMATION
a) Chief Complaint: The pt is a 60 y/o AD USAF Col physician at WRMC with newly
diagnosed prostate adenocarcinoma who presents to discuss treatment options. Briefly, the
pt had his PSA checked for the first time in Feb 201o, when it was found to be 21.28 ng/ml.
repeat PSA in April 2010 was 20.46 ng/ml. he underwent biopsy on 17May2010, which
demonstrated 8/12 cores positive for prostate adenocarcinoma, GS 3+3=6 involving <5%-
60% of each core w/ two cores positive for perineural invasion. He presents to CPDR to
discuss treatment options.
b) Medical Diagnosis: Prostate adenocarcinoma
c) Normal anatomy and physiology: The prostate gland is below the urinary bladder and
surrounds the first portion of the urethra. ( Barbara Janson Cohen) The prostate carry its
secretions helps neutralize the acidity of the vagina tract & enhance the motility of the
spermatozoa. The prostate glandis also supplied w/ muscular tissue, which upon signal from
the nervous system, contracts to aid in the expulsion of the semen from the body.
( Thibodeau- Patton) The prostate secretes a watery milk- looking and slighty acidic that
constitutes about 30% of the seminal fluid volume citrate, found in prostate fluid, serves as
nutrient for sperm. Other constitutes include enzymes and prostate specific antigen.
Prostate fluid plays an important role in sperm activation, viability, motility.
d) Pathophysiology: (J Natl Cancer Inst 202) “Adenocarcinoma is a type of cancer that
arises in the cells of the glands. Most cels in the prostate are the glandular type, which means that
adenocarcinoma is the most common type of cancer to occurin the prostate”. Cancer occurs when the
genes of a cell become abnormal, causing the cell to multiply and interfere w/ the normal function of a
tissue.
Once the cancer reaches a certain size, the abnormal cells can spread to other parts of the
body and cause cancerous tumors to grow. “Adenocarcinoma of the prostate is malignant,
howeer many types grow slowly, and so are unlikely to spread before the man dies”.
Risk factors for prostate cancer:
• Over the age of 50
• Being a male
• Smoking has been linked to prostate cancer
• Obesity
• Diet high in fat low in vegetable
e) Signs and symptoms (Christensen Kockrow)
Prostate cancer has no noticeable symptoms, when urinary symptoms are present
the cancer is in advance stages. Pt will have wil have signs and symptoms related to
urinary obstruction.
• Dull flank pain
• Sensation of needing to void
• Only able to void small amounts
• Incapacitating pain
• Nausea accompany acute pain
These symptoms are more commonly caused by benign prostatic hyperplasia or
urinary tract infection.
Other symptoms that may raise to consider include ;
• Erectile dysfunction
• Blood in the urine
• Blood in the semen

f) Complications: prostate swells up causing urinary obstruction. May lead to alterations in

blood chemistry; infection, lack of oxygen to tissue or atrophy of renal tissue.
g) Prognosis: (All prognoses from medicineNet.com, 2010)
Data suggest most men die with prostate cancer and not from it. Severity usually depends on
stage of the cancer. “ Cancer that is confined to the prostate gland is generally curable. The
prognosis is not as good if the cancer has spread locally. If the canceer has spread to other parts
 of the body such as the bones, it is very difficult to cure. Treatment is focused on the slowing of
the disease and men may still live for many years with a good quality life.
The prognosis is also related to the grade of the cancer, represented by the Gleason score,
which is a measure of how aggressive the cancer is. 40% of men with a Gleason scores of 8/10
are still alive and disease free at 10 YRS. More than 90% of men with localized tumors and
Gleason score of 2 to 4 are alive at 5 YRS.

4. DIET: ( diet obtained from www.springboard4health.com)

a) Current Diet: Clear liquid
b) Normal Diet: 2000K calorie diet (all figures provided by USDA, 2005)
• Calories: 790
• Proteins: 3%
• Carbohydrate: 92%
• Fat: 5%
• Cholesterol: 20mg
• Fiber: 3g
c) Nutritional requirements: Patient diet appears correct in my opinion for his current situation
and needs. With the patients limited activity level combined with adequate calorie intake should
be just the ticket for appropriate weight gain and of course proper healing through nutrition.
5. PATIENT TREATMENTS / PROCEDURES
a) Incentive spirometry
• Used to improve lung expansion, improve oxygenation, prevent post-operative
pneumonia.
• 10 puffs Q1HR while awake.
• Pt needs to exercise lungs due to lack of activity.
b) Vital signs Q4 HRS
• Assessment of vital signs allows nurse to identify nursing diagnosis, to implement planned
interventions, and to evaluate success when vital signs have returned to acceptable value.
• Vital sigs done every 4 hours
• Last vital signs HR 86, B/P 121/ 67, Temp 97.9 oral, SP02 98%
• Vital signs with normal limits. Will continue to monitor.
 c) Sequential compression device (SCD) to legs until ambulating.
• Sequential compression device to be used when Pt is not ambulating and lying in bed.
• Use of this device will help prevent clot formations like deep vein thrombosis.
• Patient is to have compression device while lying in bed.
• Will monitor patient use and continue patient teaching with said device.
e) Intake & Output Q4 HRS
• To ensure patient’s in-take is in balance with output
• For electrolyte balance
• Monitor all intake & Output every 4 hours.

6. LAB STUDIES
Lab Normal Patient Implication Intervention
Values Values
WBC 3.6-10.6 14.8 Possible sign of Will continue to
infection monitor and inform
MD
PLTS 150-400 187 Within limits
Hgb 12.8-17.7 12.9 Within limits
Hct 37.5-50.9 30.5 On the lower end Continue to
possibly due to monitor and inform
surgery MD
Na+ 137-145 136 Decrease possible
due to diet.
K+ 3.6-5 4.1 Within limits
Cl- 98-107 101 Within limits
CO2 22-31 28 Within limits
BUN 9-20 15 Within limits
CREAT 0.7-1.3 0.77 Within limits
Ca+ 8.4-10.2 8.4 Within limits
Gluc 75-110 106 Within limits
MCV 79.5-96.8 90.9 Within limits
MCH 26.2-33.1 32.2 Within limits
MCHC 32.6-35 34.9 Within limits
MPV 7-10.9 7.3 Within limits
RDW 12-16.2 12.5 Within limits
Mg+ 1.6-2.3 2.1 Within limits

7. REFERENCES
a. Davis’s Drug Guide for nurse’s 11th edition. F.A. Davis Company, 2009.
i. Referenced, 11 May 2010. < http://www.fadavis.com
b. Foundations and adult health nursing 5th edition. Mosby, Inc. 2006
i. Referenced, 11 & 19 May 2010. References include companion CD-rom.
c. Essentials of Medical-Surgical Nursing fourth Edition. Saunders.
i. Referenced 22 July 2010.
d. “Prostate Cancer (adenocarcinoma of the prostate) “
i. Referenced, 22 July 2010, www.virtualmedicalcentre.com.
e. Structure & Function of the human body, 7th edtion, Memmler’s
i. Referenced 22 July 2010
f. Anatomy & physiology 6th edtion, Thibodea- Patton
i. Referenced 22 July 2010