UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Emma Fleck |

|Patient Assessment Tool . |Assignment Date: 8/27/13 |

| ( 1 PATIENT INFORMATION |Agency: FHT |

|Patient Initials: T.D |Age: 59 |Admission Date: 8/26/13 |

|Gender: Male |Marital Status: Divorce, single |Primary Medical Diagnosis with ICD-10 code: ICD-10-CM I48 |

|Primary Language: English |Atrial fibrillation |

|Level of Education: Some college |Other Medical Diagnoses: (new on this admission) |

|Occupation: Research at The Reynolds and Reynolds Company |Prostate Carcinoma , hypercholesterolemia |

|Number/ages children/siblings: | |

|Two children Son 28,,Daughter 25. | |

| | |

|Three siblings, Two older brothers and a younger sister. 61, 63, 57 | |

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

|Living Arrangements: Lives by himself with a dog and is about to move into a town house |Advanced Directives: |

|with stairs. |If no, do they want to fill them out? No/No |

| |Surgery Date: none Procedure: monitor A-Fib, Cardiac |

| |Stress Test |

|Culture/ Ethnicity /Nationality: American, Western Europe descent | |

|Religion: Raised Catholic |Type of Insurance: PPO Health Insurance |

|( 1 CHIEF COMPLAINT: |

|Patient has Atrial fibrillation. |

| |

| |

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

| |

|Patient was at doctor’s office receiving a checkup and a physical examination when the doctor noticed irregular heartbeat. Patient received an EKG and doctor |

|diagnosed patient with a-fib. When patient arrived to the ER on 8/26., he denies any chest pain, pain, shortness of breath, palpitations, any nausea or vomiting, |

|fluttering or syncope. |

| |

| |

| |

| |

| |

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

|Date |Operation or Illness |

|2009 |Right shoulder rotator cuff tear |

|2010 |Right knee surgery |

|2010 |Cyst on thumb removed |

|Early 2013 |Prostate Carcinoma |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| | |

| | |

| |Patient stats that onset for his family’s medical problems occurred in early 50s |

| | |

| | |

| | |

|( 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 (Date) | |X |

|Adult Tetanus (Date) | |X |

|Influenza (flu) (Date) | |X |

|Pneumococcal (pneumonia) (Date) 2012 |X | |

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

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

|REACTIONS |Causative Agent | |

|Medications |None | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, |Pollen |Sinus infection, sneezing and watery eyes |

|etc.) | | |

| |Ragweed |Sneezing and watery eyes |

| | | |

| | | |

|( 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) |

|Atrial fibrillation is the most common dysrhythmia that is characterized by a rapid heart rate, palpitations, and irregular heart rate. The cells in the atria get |

|irritable due to cardiac muscle hypoxia, which initiates electrical pulse. This electrical pulse causes the atria to spasm instead of contracting effectively. With|

|the loss of the atrial kick, blood starts to pool leading to increased incidence of clots and stroke. Risk factors for developing atrial fib are age, white, male, |

|and having a family history of a-fib. Diagnostic test is an EKG that shows the hearts rhythm without a distinctive P wave. The treatment for a-fib includes: |

|electrical cardioversion, anticoagulation therapy, catheter ablation, and possible open heart surgery to maintain a normal heart rhythm. The prognosis is that some|

|people can live long lives with atrial fibrillation as long as they avoid triggering factors (coffee, alcohol, stress, intense activity) and if they follow the |

|physician’s orders. Otherwise those with atrial fibrillation are at an increased risk of developing a stroke and heart failure (Osborn, Wraa, & Watson, 2010). |

| |

| |

| |

( 5 Medications: References nursing central davis drug guide*

|Name: Tamsulosin (Flomax) |Concentration (mg/ml) 0.4 mg |Dosage Amount (mg) 0.4mg 1 cap |

|Route: p.o |Frequency 1 cap daily |

|Pharmaceutical class: peripherally acting antiadrenergic |Both |

|Indication: management of outflow obstruction in male patients with prostatic hyperplasia |

|Side effects/Nursing considerations: SE: dizziness, headache, and orthostatic hypotension. Emphasize importance of continuing medication even when feeling unwell. |

|May cause dizziness and should avoid driving, change positions slowly, assess symptoms of prostatic hyperplasia |

| |

|Name: Fish oil |Concentration 1,000 mg |Dosage Amount 3 Capsules |

|Route: p.o |Frequency: 3 cap daily |

|Pharmaceutical class: supplements |Home |

|Indication: Reduce levels of triglycerides and raise HDL (good) cholesterol levels in the blood. |

|Side effects/Nursing considerations |

|Easy bruising or bleeding, Abdominal discomfort, Loose stools. |

| |

|Name: Sodium Chloride 0.9% |Concentration Amount 250 mL |Dosage |

|Route: IV |Frequency |

|Pharmaceutical class: supplements | Hospital |

|Indication: maintenance of fluid and electrolyte status, dilute other medications |

|Side effects/Nursing considerations: SE: HF, pulmonary edema, hypernatremia. NC: use cautiously in patients prone to electrolyte abnormalities, assess lungs and |

|edema |

| |

|Name: Aspirin |Concentration 325 mg |Dosage Amount 1tab |

|Route: p.o |Frequency: 1 tab daily |

|Pharmaceutical class: salicylates | Hospital |

|Indication: decreases platelet aggregation |

|Side effects/Nursing considerations: SE: GI bleeding, nausea, allergic reactions, anemia. NC: use cautiously in in hx of GI bleeding, renal disease, check for |

|bleeding, take with food. Monitor for overdose and lab results. |

| |

|Name: Enoxaparin (Lovenox) |Concentration 40mg |Dosage Amount 1 injection |

|Route: SC injection |Frequency: 1 daily |

|Pharmaceutical class: anticoagulants | Hospital |

|Indication: Prevention of thrombus formation |

|Side effects/Nursing considerations: SE: dizziness, bleeding, anemia, urinary retention. NC: assess signs of bleeding, thrombosis, monitor for side effects, and |

|monitor CBC. |

| |

|PRN |

|Name Nitroglycerin |Concentration 0.4 mg/tab |Dosage Amount: 0.4 1 tab |

|Route: sublingual tab |Frequency q 5min for 3 additional doses |

|Pharmaceutical class: antianginals, nitrates | Hospital |

|Indication: relief or prevention of angina attacks, increases cardiac output, reduction of BP. |

|Side effects/Nursing considerations SE: orthostatic hypotension, headaches, and tachycardia. NC: move positions slowly for orthostatic hypotension, advise patient |

|to notify provider if dry mouth or blurred vision occurs. Keep tablet under tongue until dissolved. Monitor BP and pulse before and after administration |

| |

|PRN |

|Name: Ondansetron (Zofran) |Concentration 4mg |Dosage Amount 1 Tab |

|Route p.o |Frequency: PRN, q 4 hours |

|Pharmaceutical class: antiemetic | Hospital |

|Indication: prevention of nausea and vomiting |

|Side effects/Nursing considerations: headache, dizziness, constipation. NC: monitor ECG in patients with hypokalemia, HF, assess for extrapyramidal side effects, |

|assess patient for nausea, vomiting, distension, and bowel sounds before and after administration |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? NPO |Analysis of home diet (Compare to “My Plate” and |

|Diet pt follows at home? Regular |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | |

|Breakfast: Patient says he usually just eats a granola bar in the morning and |As stated by the patient he does not eat the best. Since the patient has |

|coffee. |hypercholesterolemia and new a-fib, the patient should eat a heart healthy diet, |

| |low in in fats and salt. Alcohol and caffeine are both known triggers of AF and |

| |therefore should be limited. The patient should broil or grill chicken, fish, and|

| |lean beef, steam vegetables, and eat unprocessed whole grains. Patient needs to |

| |eat a better breakfast start packing a lunch so he doesn’t consume fast foods |

| |high in fat and sodium. |

| | |

|Lunch: Patient says he usually goes out to eat at local restaurants and gets | |

|sandwiches, tacos, and salads | |

| | |

|Dinner: He usually has some sort of meat and a carb as a side. | |

| | |

|Snacks: granola bar | |

| | |

|Liquids (include alcohol): he has alcohol occasionally, water, tea, soda, coffee | |

| | |

|[pic] |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? “My daughter I guess. But my dog usually always there for me and comforts me.” |

| |

|How do you generally cope with stress? or What do you do when you are upset? |

|Patient states that he goes on walks but mostly keeps to himself and seeks privacy. |

| |

| |

| |

|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|Patient claims that he does not feel overwhelmed. He does state that he wishes he was closer to his children. |

| |

| |

| |

|+2 DOMESTIC VIOLENCE ASSESSMENT |

| |

|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

| |

|Have you ever felt unsafe in a close relationship? ________no_______________________________________________ |

| |

|Have you ever been talked down to?_______no________ Have you ever been hit punched or slapped?  ____no__________ |

| |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|____________________________________no______ If yes, have you sought help for this?  ______________________ |

| |

|Are you currently in a safe relationship? He is single |

| |

| |

|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s 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. XSelf absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: “Generativity versus stagnation is the seventh stage of Erik Erikson’s theory of psychosocial development. This stage takes place during |

|middle adulthood between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them; often by having |

|children or contributing to positive changes that benefits other people. Stagnation refers to the failure to find a way to contribute. These individuals may feel |

|disconnected or uninvolved with their community and with society as a whole. Those who are successful during this phase will feel that they are contributing to the|

|world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world” (Cherry, 2013). |

| |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|I believe that he falls into stagnation due to the fact that he seems to have a hard time with the relationships of his children |

|Due to the fact that he says that his dog helps him with stress more than his kids. He went through a divorce and tells me that he is more isolated. |

| |

| |

| |

| |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|A-fib can be triggered due to emotional stress and other factors. He needs to build his relationships with his children so |

|If his symptoms get worse he can have emotional support from them. |

| |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” Patient states that his a-fib is caused by heredity, bad habits, and not being active. |

| |

| |

| |

|What does your illness mean to you? Patient believes that his bad habits finally caught up to him. He feels that his illness will make him change his ways and be |

|more active. |

| |

| |

| |

|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

| |

|Have you ever been sexually active?____yes________________________________________________________________ |

|Do you prefer women, men or both genders? ______women______________________________________________________ |

|Are you aware of ever having a sexually transmitted infection? ____no_______________________________________ |

|Have you or a partner ever had an abnormal pap smear?______no_________________________________________ Have you or your partner received the Gardasil (HPV) |

|vaccination? _no______________________________________ |

| |

|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?  ___________condom_______________________ |

| |

|How long have you been with your current partner?_____Patient is single____________________ |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  heart and prostate_____________________ |

| |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|No |

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

What importance does religion or spirituality have in your life?

Religion is not important to the patient., he currently is not practing._________________________________________________________________________

Do your religious beliefs influence your current condition?

_No__________________________________________________________________________________________________

______________________________________________________________________________________________________

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes |

| If so, what? |How much?(specify daily amount) |For how many years? 15 years |

|Used to smoke cigarettes |½ pack a day |(age 16 thru 31 ) |

| | | |

|Pack Years: | |If applicable, when did the patient quit? 28 |

| | |years ago |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? No|Has the patient ever tried to quit? Yes |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes |

| What? Beer and wine |How much? (give specific volume) |For how many years? many |

| |He drinks beer and wine occasionally |(age thru ) |

| | | |

| If applicable, when did the patient quit? He still drinks | | |

|occasionally | | |

| |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

| | | |

| Is the patient currently using these drugs? No |If not, when did he/she quit? | |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|No |

| |

| |

| |

| |

| |

| |

| |

| |

( 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 |X Tumor |

| Use of sunscreen None SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: everyday |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? Never had one | |

|HEENT |Other: |Hematologic/Oncologic |

|X Difficulty seeing (wears glasses) |Genitourinary | Anemia |

| Cataracts or Glaucoma |X nocturia | Bleeds easily |

|X Difficulty hearing (some loss in left ear) | dysuria | Bruises easily |

| Ear infections | hematuria |X Cancer |

|X Sinus pain or infections (with his allergies) |X polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: |

| Post-nasal drip |Normal frequency of urination: 7/day |Other: |

| Oral/pharyngeal infection | Bladder or kidney infections | |

| Dental problems | |Metabolic/Endocrine |

|X Routine brushing of teeth 2/day | | Diabetes Type: |

|X Routine dentist visits twice ayear | | Hypothyroid /Hyperthyroid |

|X Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |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 |X Infection of male genitalia/prostate? | Depression |

|X Hyperlipidemia |X Frequency of prostate exam? 1 year | Schizophrenia |

| Chest pain / Angina | Date of last prostate exam? December | Anxiety |

|Myocardial Infarction |X BPH | Bipolar |

| CAD/PVD |X Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Murmur |X Injuries or Fractures (used to) |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

|X Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? 8/26/13 |Arthritis |X Chicken Pox |

|Other: |Other: |Other: |

| | | |

|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 |

| |

| |

| |

| |

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

|General Survey: |Height: 185 cm |Weight: 211 lb BMI: 30 |Pain: (include rating & location) |

| | | |none |

| |Pulse: 78 |Blood | |

| | |Pressure: 124/90 arm | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations: 16 | | |

|Oral 98.5 | | | |

| |SpO2 99 |Is the patient on Room Air or O2: Room air |

|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |

|X 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] |

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

| |

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

|X clear, crisp diction |

| |

|Mood and Affect: X pleasant X cooperative X cheerful X talkative quiet boisterous flat |

| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |

|Other: |

|Integumentary | |

|X Skin is warm, dry, and intact | |

|X Skin turgor elastic | |

|X No rashes, lesions, or deformities | |

|X Nails without clubbing | |

|X Capillary refill < 3 seconds | |

|X Hair evenly distributed, clean, without vermin | |

| | |

| | |

| | |

| | |

|X Peripheral IV site Type: 20g Location: AC Date inserted: 8/26 |

| X no redness, edema, or discharge |

| Fluids infusing? no X yes – what? Normal Saline |

| 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: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline |

|X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge |

|X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

|X PERRLA pupil size / 3 mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus |

|X Ears symmetric without lesions or discharge X Whisper test heard: right ear- 7 inches & left ear- 5 inches |

| X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: |

|Comments: |

| |

|Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric |

| | |X Lungs clear to auscultation in all fields without adventitious sounds |

| |CL – Clear |X 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 |*All lobes in the lungs are clear |

| |Ab – Absent | |

| | | |

| | | |

|Cardiovascular: X No lifts, heaves, or thrills PMI felt at: 5 ICS |

|Heart sounds: X S1 S2 Regular X slightly irregular X No murmurs, clicks, or adventitious heart sounds X No JVD |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) |

| |

|(At end of paper)* |

|X Calf pain bilaterally negative X 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 |

|X 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: none pitting non-pitting |

|X Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

| |

| |

|GI/GU: X Bowel sounds active x 4 quadrants; no bruits auscultated X No organomegaly |

|X Percussion dull over liver and spleen and tympanic over stomach and intestine X Abdomen non-tender to palpation |

|Urine output: X Clear Cloudy Color: yellow Previous 24 hour output: mLs N/A |

|Foley Catheter Urinal or Bedpan X Bathroom Privileges without assistance |

|X CVA punch without rebound tenderness |

|Last BM: (date 8 / 26 / 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 X Not assessed, patient alert, oriented, denies problems |

| Other – Describe: |

| |

| |

|Musculoskeletal: X Full ROM intact in all extremities without crepitus |

|X 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] |

|X vertebral column without kyphosis or scoliosis |

|X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias |

| |

| |

| |

|Neurological: X Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam |

|X CN 2-12 grossly intact X Sensation intact to touch, pain, and vibration X Romberg’s Negative |

|X Stereognosis, graphesthesia, and proprioception intact X 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: |

|negative |

| |

|*Did not have tools to perform DTR test, but assuming that all DTR are +2 |

| |

| |

|±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): |

| |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|Troponon T 0.01 |

|0.01 |

|8/26, 8/27 |

| |

|Patient’s troponin levels were low both times. |

|A high troponin T would indicate a heart attack. This lab test shows that the patient did not have one. A MI can cause a-fib. |

| |

|Echocardiography |

|8/27 (did not see results) |

| |

|It is expected to be done to help identify valvular heart disease, show the size of the left and right atrial, and to see if there are any clots. |

| |

|INR 2, 2.2 |

|8/26, 8/27 |

|Patient’s INR remained the same |

|It is expected that the INR is between 2-3 if patient is on anticoagulant therapy. |

| |

|PTT 22, 220 |

|8/26, 8/27 |

|no definite change |

|It is important to check platelet count to see if the patient with a-fib is at risk for clots or at risk of bleeding. |

| |

|ECG |

|8/26, 8/27 |

|Findings show that there are no distinct P waves. |

|Due to irregular conduction there are no P waves. This determines that the patient has a-fib. |

| |

|Hemoglobin 16, 16.4 |

|8/26, 8/27 |

|no definite changes |

|13.5-17.5 grams/dL is the normal range for males. 16.4 is within normal values. If lower patient has a bleed, high means more likely to clot |

| |

|RBC 5 million, 5.1 million |

|8/26.8/27 |

|no definite change |

|4.3 to 6 million cells/mm3. Patient is within normal lab value. Low means patient has a bleed high means more likely to clot. |

| |

|WBC7400,7410 |

|8/26, 8/27 |

|no definite change |

|Normal lab values(3,500 to 10,500 cells/mcL) Patient is within normal range, too high indicates infection and too low means patient is prone to infection |

| |

| |

|*labs values from hospital computers |

| |

| |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: |

| |

|Diet: Patient was NPO for further testing |

|Scheduled diagnostic tests: Echocardiography, Chest X-ray, blood tests to see possible causes of patient’s a-fib |

|Vitals: patient’s vitals were monitored to make sure that his heart rate was slowing down and to monitor heart rhythm. He was hooked up to a tele to monitor change |

|in sinus rhythm and monitor heart rate. |

| |

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

|1. Decreased cardiac output r/t altered electrical conduction |

| |

| |

|2. Risk for bleeding r/t anticoagulant drug therapy |

| |

| |

|3. Social isolation related to absence of supportive family members aeb patient states that he likes to be left alone in stressful situations |

| |

± 15 CARE PLAN

Nursing Diagnosis: Decreased cardiac output secondary to atrial fibrillation, aeb irregular heartbeat

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |

| | |Provide References | |

|Patient’s heart rate will stay between 60-100 beats |1) Promote emotional and physical rest (e.g. maintain|1) Rest helps reduce the workload of the heart. |1) Patient was able to relax in calm environment and |

|per minute during shift. |a calm, quiet environment; limit the number of |2) By placing the patient on a telemonitor, nurse |heart rate was in the 70s. |

| |visitors; maintain activity restrictions) |will be able to monitor heart beat and rhythm and to | |

| |2) Place patient on tele to monitor sinus and rhythm |be able to give medication based on results to keep |2) Telemonitor kept healthcare providers aware of |

| | |heart rate between 60-100 beats per minute. |patient’s heart rate and no medications were needed |

| | | |to reduce heart rate. |

| | | | |

|Patient will describe 2 ways reduce the risk of clots|1) Educate the need for anticoagulant medications |1) By understanding that the medications reduce the |1) Patient was able to describe 3 ways to reduce |

|and to demonstrate subcutaneous injections to improve|(aspirin and lovenox) to reduce clotting of the |risk for stroke, the patient is more likely to take |clots such as using SCDs, sitting in the chair, and |

|cardiac output by end of the shift. |atrial valve and describe what the medications do to |his medications and know the risk factors to call his|taking anticoagulant medications such as aspirin, |

| |reduce strokes. |doctor about. Also providing other alternative ways |lovenox, and warfarin. |

| |2) Describe how to draw up medication and how to give|to reduce clots such as movement and using SCDs while|2) Patient was able to draw up water in an insulin |

| |subcutaneous injections. |at the hospital will also reduce blood clots. |syringe and list the places that subcutaneous |

| | |2) By understanding how to give subcutaneous |injections can be given. |

| | |injections to himself, the patient will understand | |

| | |the locations and how to give himself injections if | |

| | |he were to go home with Lovenox. | |

| | | | |

|Patient will incorporate knowledge of health regimen |1) Patient teaching of taking his own pulse |1) Checking your pulse is a easy way to tell if |1) Patient was able to take his pulse and demonstrate|

|into lifestyle before the end of shift. |2) Patient will be able to describe disease process |you’re in or out of rhythm. |where radial pulses are. |

| | |2) If the patient is able to describe the disease |2) Patient was able to verbalize the disease process |

| | |process, he will understand that a-fib is a serious |of a-fib stating that the irregular rapid heart rate |

| | |disease that can cause clots that can lead to a |of the atria causes poor blood flow to the body. I |

| | |stroke |printed out informative facts about a-fib to remind |

| | | |him. |

|(Ackley& Ladwig, 2011). | | | |

| | | | |

|± 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 patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Risk for bleeding

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |

| | |Provide References | |

|Patient will verbally state 2 side effects of |1) Teach patient to recognize the signs of bleeding |Bleeding is a risk factor when taking anticoagulants |1) Patient states excessive bruising, bleeding gums, |

|anticoagulation medications |2) Teach patient behavioral changes to avoid |to prevent strokes in patients with a-fib. If the |and bloody stool are signs of bleeding and he will |

| |bleeding. |patient understands his anticoagulant therapy he will|call his doctor. |

| | |understand the side effects of the drugs and will be |2) Patient states use to use a soft toothbrush, use |

| | |able to call his health care provider if bleeding |an electrical razor, and avoid to contact sports and |

| | |occurs |to check his INR. |

| | | | |

|Patient’s lab values (INR, H/H, RBC,)will remain in |1) lab results must be monitored in a patient taking |Anticoagulants increase bleeding to reduce blood |INR was 2, RBC 5.1million/mcl, platelets 220,000/mL, |

|normal range during shift and there will be no signs |anticoagulants |clots. If the patient is bleeding, the labs and |hemoglobin 16.4g/dl. Patient’s labs remained in |

|of bleeding |2) assessments for bleeding q2h |assessments will determine it. |normal ranges. |

| | |Assessment of excessive bruising, looking at urine |There were no signs of bleeding in the patient. |

| | |sample, monitoring for flu like symptoms. | |

| | | | |

| | | | |

| | | | |

|(Ackley& Ladwig, 2011). | | | |

| | | | |

| | | | |

|±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 |

|XDietary Consult |

|XPT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|□F/U appts |

|XMed Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? XYes □ No (warfarin will be more likely prescribed instead of lovenox) |

|□Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Social isolation related to absence of supportive family members aeb patient states that he likes to be left alone in stressful situations

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care |

| | |Provide References |is Provided |

|Patient will list 2 goals to partake in |1) Promote social interactions and |1) Listing goals to become social will |1)Patient will go out for lunch with |

|with others |behavioral changes |decrease the patient of feeling lonely |coworkers |

| |2) Provide positive reinforcement when |and can help with stress of having |Patient will call his children to create|

| |client seeks out others |a-fib. |better relationships with them. |

| | |2) Providing the patient with positive |2) I let the patient know that being |

| | |reinforcement lets him know that by |involved with coworkers and talking to |

| | |having relationships will help him |his children are good ideas. |

| | |decrease stress and not have support. | |

| | | | |

| | | | |

|Have one meaningful/ therapeutic |1) Establish a therapeutic relationship |1) Being available to talk to the |1) I demonstrated active listening |

|relationship during time stayed at |by being emotionally present |patient decrease feelings of loneliness.|skills by listening to what he had to |

|hospital |2) Observe for barriers to social |2) Observing barriers to social |say such as that he and his kids are not|

| |interaction |interaction can let the patient know |that close and talked about our dogs, |

| | |what attitudes need to be changed to be |and other concerns about his condition. |

| | |more social. |He was able to have a therapeutic |

| | | |relationship. |

| | | |2) I observed that he have some barriers|

| | | |to social interaction such as releasing |

| | | |his real feelings and he has problems |

| | | |having relationships with his children. |

| | | | |

|(Ackley& Ladwig, 2011). | | | |

| | | | |

|± 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 patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

[pic]

References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to

planning care. (9th ed.). St.Louis,Missouri: Mosby Elsevier.

Cherry, K. (2013). Generativity Versus Stagnation. Retrieved from



Nursing Central Unbound Medicine, Davis’s Drug Guide 2012

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing: preparation for practice. Upper

Saddle River, N.J.: Pearson Prentice Hall.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download