UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Rachel Barkwell |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 2/3/15 |

| ( 1 PATIENT INFORMATION |Agency: FHT |

|Patient Initials: C. H. |Age: 57 |Admission Date: 1/24/15 |

|Gender: Male |Marital Status: Divorced |Primary Medical Diagnosis |

|Primary Language: English |Acute CHF exacerbation (I50.9) |

|Level of Education: High School |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): retired law enforcement |Acute pneumonia (J18.1) |

|Number/ages children/siblings: 1 daughter (20); |Hyperkalemia (E87.5) |

|2 brothers (65, 62) and 1 sister (59) | |

| | |

|Served/Veteran: No |Code Status: Full Resuscitation |

|If yes: Ever deployed? N/A | |

|Living Arrangements: Pt. lives in a house alone. Pt. states that there are no stairs |Advanced Directives: No |

|inside the house or at the entry of the house. |If no, do they want to fill them out? No |

| |Surgery Date: N/A Procedure: N/A |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: None |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: |

|“I was having trouble breathing and I was coughing and wheezing – my chest felt tight. It is still hard for me to lay down flat and breathe.” |

| |

|( 3 HISTORY OF PRESENT ILLNESS: |

|Pt. is a 57 y.o. male admitted to the ED via EMS from a wound care clinic for dyspnea. Pt. states he has had difficulty breathing for the last week but it has |

|progressively become worse. Today while at a wound care clinic the dyspnea became severe. Pt. states the course has been constant and progressive. Pt. states his|

|chest feels “tight”. The pt. reports associated symptoms of coughing, wheezing, and bilateral leg swelling. Pt. also reports coughing up yellow sputum with |

|“hints of pink”. Pt. denies chest pain or fever. Pt. reports exacerbating factor is lying flat and finds some relief by sitting upright. Upon arrival to the ED,|

|the pt.’s O2 saturation was 90% - nasal cannuli O2 was applied and beta-agonist albuterol breathing treatment was started. O2 saturation increased up to 99%. CXR|

|and chest CT was ordered. The chest CT revealed vascular congestion, cardiomegaly, suspicious pulmonary edema, and possible PNA. The pt. also had a lower |

|extremity venous US ordered which was negative for DVTs. The pt. was diagnosed with CHF exacerbation, PNA, and positive for MRSA. The pt. was then transferred up|

|to the progressive ICU – 4N. Today the pt. is ready for discharge and will be transferred back to Brandon Health and Rehabilitation Center. |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|2003 |Stroke w/ right side hemiparesis |

|“in my 30s” |Type 2 DM |

|2013 |Adenectomy |

|“in my early 50s” |Chronic Kidney Disease (stage IV) |

|“in my late 40s” |CHF |

|“in my 30s” |HTN |

|“in my 20s” |Hypothyroidism |

|“in my 40s” |GERD |

|“Early 2000s” |Mitral valve prolapse & hernia repair |

|“I don’t remember” |A-Fib |

|“I don’t remember” |Chronic anemia |

|( 2 FAMILY MEDICAL HISTORY |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations |X | |

|Routine adult vaccinations for military or federal service | |X |

|Adult Diphtheria (U) |X | |

|Adult Tetanus (U) Is within 10 years? U |X | |

|Influenza (flu) (01/14/2015) Is within 1 years? Yes |X | |

|Pneumococcal (pneumonia) (3/25/2013) Is within 5 years? Yes |X | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | |X |

If yes: give date, can state “U” for the patient not knowing date received

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |NKDA |N/A |

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|Other (food, tape, latex, dye, |NKDA |N/A |

|etc.) | | |

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|( 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) |

|Heart failure (HF) occurs when the heart muscle becomes weakened and is unable to pump sufficient blood to meet the metabolic needs of the body. Because of this |

|decreased pumping ability, less blood may reach organs throughout the body limiting oxygen and nutrient supply. “The result of inadequate cardiac output (CO) is |

|poor organ perfusion and vascular congestion in the pulmonary or systemic circulation.” Pulmonary or systemic circulation is caused by a backup of fluid into the |

|heart and lungs and other systemic areas like the legs or abdominal area. This buildup of fluid in the tissues is why heart failure is sometimes referred to as |

|congestive heart failure (CHF). HF does not mean that your heart has failed completely; rather it has become weaker and less able to pump efficiently. “HF may be |

|described as backward or forward failure, high- or low-output failure, or right- or left-sided failure. HF may result from a number of causes that affect preload |

|(venous return), afterload (impedance the heart has to overcome to eject its volume), or contractility.” Some examples of risk factors that may lead to HF are |

|hypertension, incompetent valves, MI, CAD, cardiomyopathy, diabetes, infection of the heart, lung disease, renal failure, and arrhythmias. “HF is a complex |

|disease combining the actions of several genes with environmental factors. Many risk factors have genetic causes or are associated with genetic predispositions.” |

|HF may occur at any age and in both genders, however elderly people are much more prone to the condition because of contributing chronic disorders that are more |

|prevalent in the elderly population. As compared with whites, the incidence and prevalence of HF are higher in African Americans, Hispanic/Latinos, and Native |

|Americans – which is thought to be a result of gene variation. “Although men and women have similar rates of HF, women tend to have the condition later in life |

|than men.” There are multiple diagnostic tests that may be performed to diagnosis HF. An echocardiogram is the most common method of diagnosis. An echo can |

|measure chamber size, valvular structure and function, ventricular wall motion, and an estimated ejection fraction (EF). The normal EF is 55% - 70%; HF is |

|diagnosed when the EF is below 40%. Other diagnostic tests that may be performed are multigated blood pool imaging, BNP, cMRI (cardiac MRI), CXR, |

|electrocardiography, etc. Treatment is dependent on the severity of HF, symptoms, etiology, presence of other illness, and precipitating factors. Treatment is |

|usually pharmacological – vasodilators, diuretics, and digoxin. However there may be surgical interventions and procedures, as well as management of symptoms |

|including supplemental oxygen, positioning, modified lifestyle changes, etc. Prognosis depends on the severity of HF and management of symptoms. To control |

|symptoms and CHF exacerbation ongoing monitoring throughout the acute phase is important. (Sommers, 2013). |

( 5 Medications: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN medication . Give trade and generic name.]

|Name aspirin (Aspir-low) |Concentration 81 mg/tablet |Dosage Amount 81 mg |

|Route Oral |Frequency once daily |

|Pharmaceutical class salicylates |Home Hospital or Both |

|Indication prophylaxis of transient ischemic attacks and MI |

|Adverse/ Side effects GI bleeding, dyspepsia, nausea, abd. pain, tinnitus, anemia, rash |

|Nursing considerations/ Patient Teaching report unusual bleeding of gums, bruising, black, tarry stools; take with a full glass of water and remain in upright |

|position for 15-30 min after administration; avoid concurrent use of alcohol to minimize possible gastric irritation |

|Name bumetanide (Bumex) |Concentration 1 mg/tablet |Dosage Amount 1 mg |

|Route Oral |Frequency once daily |

|Pharmaceutical class Loop diuretic |Home Hospital or Both |

|Indication edema due to heart failure |

|Adverse/ Side effects dehydration, hypokalemia, hyponatremia, hypovolemia, dizziness, hypotension, diarrhea, excessive urination, Steven-Johnson syndrome |

|Nursing considerations/ Patient Teaching increased fall risk for geriatrics, caution pt. to change positions slowly to minimize orthostatic hypotension, monitor |

|blood glucose closely – may cause increased levels, consult health care professional regarding diet concerning potassium |

|Name carvedilol (Coreg) |Concentration 6.25 mg/tablet |Dosage Amount 6.25 mg |

|Route Oral |Frequency twice daily |

|Pharmaceutical class beta-blocker |Home Hospital or Both |

|Indication hypertension, heart failure |

|Adverse/ Side effects bradycardia, HF, pulmonary edema, dizziness, fatigue, weakness, bronchospasm, wheezing, diarrhea, ED, hyperglycemia, angioedema, |

|Steven-Johnson syndrome |

|Nursing considerations/ Patient Teaching take medication as directed & do not withdraw abruptly; check pulse daily and BP biweekly - hold dose & contact provider |

|if pulse is ................
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