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UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSINGStudent: Emily MorganPatient Assessment Tool .Assignment Date: 9/24/13 1 PATIENT INFORMATION Agency: Sarasota MemorialPatient Initials: R.S. Age: 88Admission Date: 9/22/13 Gender: Male Marital Status: MarriedPrimary Medical Diagnosis with ICD-10 code:Primary Language: EnglishAngina. Acute Myocardial Infarction Level of Education: Bachelor’sOther Medical Diagnoses: (new on this admission)Occupation (if retired, what from?): Retired TeacherNumber/ages children/siblings: 1 Daughter: 53 1 Son: 55Served/Veteran: NoCode Status: FullLiving Arrangements: At home with his wife. Advanced Directives: YesIf no, do they want to fill them out?Surgery Date: n/a Procedure:Culture/ Ethnicity /Nationality: SwedishReligion: CatholicType of Insurance: BCBS, Medicare 1 CHIEF COMPLAINT: Chest pain. “Pressure on my chest” 3 HISTORY OF PRESENT ILLNESS: Onset: “Just before I arrived” Location: ChestDuration: ConstantCharacteristics: Moderate pain at the peak.Associated/Aggravating Factors: Diaphoresis. Patient claims than nothing makes it worse.Relieving Factors: Patient claims that nothing makes it better.Treatment: The patient’s symptoms and health conditions are being treated and the patient has responded well. So far He denies any further chest pain but he is being monitored for any changes. 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operationDate Operation or Illness“Fifteen yrs ago”Hypertension“Fifteen yrs ago”Diabetes“Fifteen yrs ago”Hypercholesterolemia1980Appendectomy2000Back surgery 2005Knee surgery2003Cataract surgery 2 FAMILY MEDICAL HISTORYAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFatherMI FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX MotherBreast Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sister FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX relationship FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: Include date of onsetPatient couldn’t recall date on onset for either parents. 1 immunization History (May state “U” for unknown, except for Tetanus, Flu, and Pna)YesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (Date) Patient couldn’t confirm vaccination. FORMCHECKBOX FORMCHECKBOX Adult Tetanus (Date) Less than five years ago. FORMCHECKBOX FORMCHECKBOX Influenza (flu) (Date) FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (Date) Since the age of 65 FORMCHECKBOX FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX FORMCHECKBOX 1 ALLERGIES OR ADVERSE REACTIONSNAME of Causative AgentType of Reaction (describe explicitly)MedicationsPenicillinItching/rashTramadolItching/rashOmnicefItching/rashNaproxenCoughOther (food, tape, latex, dye, etc.)TapeItching/rash 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 Heuther and McCance (2012, pp. 607), the first symptom of acute myocardial infarction is usually sudden, Severe chest pain. The pain may be described as heavy and crushing. In the case of my patient, he described his pain as “pressure on my chest.” When coronary blood flow is interrupted for an extended period of time, myocyte necrosis Occurs. This results in myocardial infarction (MI). Risk factors include hypertension, diabetes, and hypercholesterolemia. My patient possesses all of the stated risk factors. In fact, the most specific indicator of an MI is a rise in troponin plasma Levels. It has been noted that my patient’s troponin levels are abnormally high, which has lead to his diagnosis. Treatment Focuses on pain management and monitoring cardiac rhythms and well as enzymatic changes. This is essential because The first 24 hours after the onset of symptoms is the time of highest risk for sudden death. In the case of my patient, his Pain seems to have stabilized and he is being continuously monitored for any abrupt changes. Huether & McCance, K. (2012) Understanding Pathophysiology. 5th Edition. (pp. 605-607) St. Louis, MO: Elsevier Mosby Inc. 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]Name OmeprazoleConcentration (mg/ml)Dosage Amount (mg) 20 mgRoute POFrequency: DailyPharmaceutical class: Proton Pump Inhibitors Hospital Indication: HeartburnSide effects/Nursing considerations: May cause dizzinessName: Amlodipine ConcentrationDosage Amount 5 mgRoute: POFrequency DailyPharmaceutical class: Calcium Channel BlockerBothIndication: Hypertension, anginaSide effects/Nursing considerations: Monitor BP Name: Enoxaparin Concentration: 30 ml Dosage Amount: Route: Subcu InjFrequency: DailyPharmaceutical class: Antithrombotics Hospital Indication: Prevention of DVTSide effects/Nursing considerations: May increase bleedingName Glipizide ConcentrationDosage Amount: 5 mgRoute: POFrequency: Every other dayPharmaceutical class: Sulfonylureas BothIndication: Controls blood sugar in Type 2 DiabetesSide effects/Nursing considerations: Monitor blood glucose levels Name Finasteride ConcentrationDosage Amount: 5 mgRoute: POFrequency: DailyPharmaceutical class: Androgen Inhibitors BothIndication: BPHSide effects/Nursing considerations: Use cautiously in patients with hepatic impairment. Name: Spironolactone ConcentrationDosage Amount: 25 mgRoute: POFrequency: DailyPharmaceutical class: Potassium Sparing Diuretics BothIndication: HypertensionSide effects/Nursing considerations: Monitor K levels 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.Diet ordered in hospital? 2 gm Sodium Analysis of home diet (Compare to “My Plate” and Diet pt follows at home? RegularConsider co-morbidities and cultural considerations):24 HR average home diet:Fruits: My patient did not mention any consumption of Breakfast: Coffee and a muffin. Spinach or oatmeal.Fruits in his diet. Fruits can greatly decrease the risk of MISo this would be very important to incorporate into his diet.Lunch: Ham sandwich with lettuce.Vegetables: Although spinach is sometimes consumed, I Am not convinced that he gets enough. Veggies can reduceDinner: Sometimes milk and cookies. Sometimes chicken.The risk for heart disease.Protein: On a good day is seems as though he might get Snacks: Applesauce, pudding, ice cream. Enough protein. Protein can help keep the body strong and Help the immune system. Liquids (include alcohol):Oils: Due to my patient admitting to having cookies for Dinner is seems as though he needs to cut back on his sweets. This could really benefit him due to his DM. 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 wife”How do you generally cope with stress? or What do you do when you are upset? “I talk to my wife about it. She usuallyMakes me feel better.”Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) “This is kindof frustrating, being here.”+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??No__________________Are you currently in a safe relationship?Yes 4 DEVELOPMENTAL CONSIDERATIONS:Erikson’s stage of psychosocial development: FORMCHECKBOX Trust vs. FORMCHECKBOX Mistrust FORMCHECKBOX Autonomy vs. FORMCHECKBOX Doubt & Shame FORMCHECKBOX Initiative vs. FORMCHECKBOX Guilt FORMCHECKBOX Industry vs. FORMCHECKBOX Inferiority FORMCHECKBOX Identity vs. FORMCHECKBOX Role Confusion/Diffusion FORMCHECKBOX Intimacy vs. FORMCHECKBOX Isolation FORMCHECKBOX Generativity vs. FORMCHECKBOX Self absorption/Stagnation FORMCHECKBOX Ego Integrity vs. FORMCHECKBOX DespairCheck 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: Older adults need to look back on life and feel a sense of fulfillment. Success at this age leads to feelings of Wisdom, while failure results in regret, bitterness, and despair. Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:I would describe my patient as being in the ego integrity stage of his life. Although he is frustrated about his Hospitalization, he turns to his wife for support and it doesn’t seem to affect him too much. He seems to be a happy Older man and showed no signs of despair when I was talking with him. Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: My patienthas experienced feelings of frustration towards his hospitalization but it hasn’t affected his developmental stage of life.+3 CULTURAL ASSESSMENT: “What do you think is the cause of your illness?” “My habits”What does your illness mean to you? “It means I should start taking better care of myself” +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?? _____n/a__________________________How long have you been with?your current partner?_50 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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)What importance does religion or spirituality have in your life? __”I read the bible everyday”____________________________________________________________________________________________________________________________________________________________________________________Do your religious beliefs influence your current condition?_”Yes”__________________________________________________________________________________________________________________________________________________________________________________________________+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? 43yearsCigarettesPack a day(age 25 thru 68 )Pack Years:If applicable, when did the patient quit? 20 yrs agoDoes anyone in the patient’s household smoke tobacco? If so, what, and how much?Has the patient ever tried to quit? YesNo2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes What?How much? (give specific volume)For how many years?WineSocially (age thru )Hasn’t in a long time, couldn’t If applicable, when did the patient quit?recall3. 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? NoIf not, when did he/she quit?4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/RisksThe patient is not currently exposed to any risks. 10 Review of SystemsGeneral ConstitutionGastrointestinalImmunologic FORMCHECKBOX Recent weight loss or gain FORMCHECKBOX Nausea, vomiting, or diarrhea FORMCHECKBOX Chills with severe shakingIntegumentary FORMCHECKBOX Constipation FORMCHECKBOX Irritable Bowel FORMCHECKBOX Night sweats FORMCHECKBOX Changes in appearance of skin FORMCHECKBOX GERD FORMCHECKBOX Cholecystitis FORMCHECKBOX Fever FORMCHECKBOX Problems with nails FORMCHECKBOX Indigestion FORMCHECKBOX Gastritis / Ulcers FORMCHECKBOX HIV or AIDS FORMCHECKBOX Dandruff FORMCHECKBOX Hemorrhoids FORMCHECKBOX Blood in the stool FORMCHECKBOX Lupus FORMCHECKBOX Psoriasis FORMCHECKBOX Yellow jaundice FORMCHECKBOX Hepatitis FORMCHECKBOX Rheumatoid Arthritis FORMCHECKBOX Hives or rashes FORMCHECKBOX Pancreatitis FORMCHECKBOX Sarcoidosis FORMCHECKBOX Skin infections FORMCHECKBOX Colitis FORMCHECKBOX Tumor FORMCHECKBOX Use of sunscreen SPF: 50 FORMCHECKBOX Diverticulitis FORMCHECKBOX Life threatening allergic reactionBathing routine: FORMCHECKBOX Appendicitis FORMCHECKBOX Enlarged lymph nodesOther: FORMCHECKBOX Abdominal AbscessOther: FORMCHECKBOX Last colonoscopy?HEENTOther:Hematologic/Oncologic FORMCHECKBOX Difficulty seeing Genitourinary FORMCHECKBOX Anemia FORMCHECKBOX Cataracts or Glaucoma FORMCHECKBOX nocturia FORMCHECKBOX Bleeds easily FORMCHECKBOX Difficulty hearing FORMCHECKBOX dysuria FORMCHECKBOX Bruises easily FORMCHECKBOX Ear infections FORMCHECKBOX hematuria FORMCHECKBOX Cancer FORMCHECKBOX Sinus pain or infections FORMCHECKBOX polyuria FORMCHECKBOX Blood Transfusions FORMCHECKBOX Nose bleeds FORMCHECKBOX kidney stonesBlood type if known: FORMCHECKBOX Post-nasal dripNormal frequency of urination: x/dayOther: FORMCHECKBOX Oral/pharyngeal infection FORMCHECKBOX Bladder or kidney infections FORMCHECKBOX Dental problemsMetabolic/Endocrine FORMCHECKBOX Routine brushing of teeth 2 x/day FORMCHECKBOX Diabetes Type:2 FORMCHECKBOX Routine dentist visits x/year FORMCHECKBOX Hypothyroid /Hyperthyroid FORMCHECKBOX Vision screening FORMCHECKBOX Intolerance to hot or coldOther: FORMCHECKBOX OsteoporosisOther:Pulmonary FORMCHECKBOX Difficulty BreathingCentral Nervous System FORMCHECKBOX Cough - dry or productiveWomen Only FORMCHECKBOX CVA FORMCHECKBOX Asthma FORMCHECKBOX Infection of the female genitalia FORMCHECKBOX Dizziness FORMCHECKBOX Bronchitis FORMCHECKBOX Monthly self breast exam FORMCHECKBOX Severe Headaches FORMCHECKBOX Emphysema FORMCHECKBOX Frequency of pap/pelvic exam FORMCHECKBOX Migraines FORMCHECKBOX Pneumonia Date of last gyn exam? FORMCHECKBOX Seizures FORMCHECKBOX Tuberculosis FORMCHECKBOX menstrual cycle regular irregular FORMCHECKBOX Ticks or Tremors FORMCHECKBOX Environmental allergies FORMCHECKBOX menarche age? FORMCHECKBOX Encephalitis FORMCHECKBOX last CXR? FORMCHECKBOX menopause age? FORMCHECKBOX MeningitisOther:Date of last Mammogram &Result:Other:Date of DEXA Bone Density & Result:CardiovascularMen OnlyMental Illness FORMCHECKBOX Hypertension FORMCHECKBOX Infection of male genitalia/prostate? FORMCHECKBOX Depression FORMCHECKBOX Hyperlipidemia FORMCHECKBOX Frequency of prostate exam? FORMCHECKBOX Schizophrenia FORMCHECKBOX Chest pain / Angina Date of last prostate exam? FORMCHECKBOX Anxiety FORMCHECKBOX Myocardial Infarction FORMCHECKBOX BPH FORMCHECKBOX Bipolar FORMCHECKBOX CAD/PVD FORMCHECKBOX Urinary RetentionOther: FORMCHECKBOX CHFMusculoskeletal FORMCHECKBOX Murmur FORMCHECKBOX Injuries or FracturesChildhood Diseases FORMCHECKBOX Thrombus FORMCHECKBOX Weakness FORMCHECKBOX Measles FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Pain FORMCHECKBOX Mumps FORMCHECKBOX Myocarditis FORMCHECKBOX Gout FORMCHECKBOX Polio FORMCHECKBOX Arrhythmias FORMCHECKBOX Osteomyelitis FORMCHECKBOX Scarlet Fever FORMCHECKBOX Last EKG screening, when? 9/24 FORMCHECKBOX Arthritis FORMCHECKBOX Chicken PoxOther:Other: unsteady gaitOther:Is there any problem that is not mentioned that your patient sought medical attention for with anyone? NoAny 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: NormalHeight: 70 inWeight:208 BMI:29.95Pain: (include rating & location)0Pulse: 62Blood 124/87 L armPressure:(include location)Temperature: (route taken?)97.7 OralRespirations: 18SpO2: 96Is the patient on Room Air or O2: RAOverall Appearance: [Dress/grooming/physical handicaps/eye contact] FORMCHECKBOX clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicapsOverall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] FORMCHECKBOX awake, calm, relaxed, interacts well with others, judgment intactSpeech: [e.g.: clear/mumbles /rapid /slurred/silent/other] FORMCHECKBOX clear, crisp dictionMood and Affect: FORMCHECKBOX pleasant FORMCHECKBOX cooperative FORMCHECKBOX cheerful FORMCHECKBOX talkative FORMCHECKBOX quiet FORMCHECKBOX boisterous FORMCHECKBOX flat FORMCHECKBOX apathetic FORMCHECKBOX bizarre FORMCHECKBOX agitated FORMCHECKBOX anxious FORMCHECKBOX tearful FORMCHECKBOX withdrawn FORMCHECKBOX aggressive FORMCHECKBOX hostile FORMCHECKBOX loud Other:Integumentary FORMCHECKBOX Skin is warm, dry, and intact FORMCHECKBOX Skin turgor elastic FORMCHECKBOX No rashes, lesions, or deformities FORMCHECKBOX Nails without clubbing FORMCHECKBOX Capillary refill < 3 seconds FORMCHECKBOX Hair evenly distributed, clean, without vermin FORMCHECKBOX Peripheral IV site Type: 1 Location: left wrist Date inserted: 9/24 FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? FORMCHECKBOX Peripheral IV site Type: Location: Date inserted: FORMCHECKBOX no redness, edema, or discharge Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what? FORMCHECKBOX Central access device Type: Location: Date inserted: Fluids infusing? FORMCHECKBOX no FORMCHECKBOX yes - what?HEENT: FORMCHECKBOX Facial features symmetric FORMCHECKBOX No pain in sinus region FORMCHECKBOX No pain, clicking of TMJ FORMCHECKBOX Trachea midline FORMCHECKBOX Thyroid not enlarged FORMCHECKBOX No palpable lymph nodes FORMCHECKBOX sclera white and conjunctiva clear; without discharge FORMCHECKBOX Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness FORMCHECKBOX PERRLA pupil size / mm FORMCHECKBOX Peripheral vision intact FORMCHECKBOX EOM intact through 6 cardinal fields without nystagmus FORMCHECKBOX Ears symmetric without lesions or discharge FORMCHECKBOX Whisper test heard: right ear- inches & left ear- inches FORMCHECKBOX Nose without lesions or discharge FORMCHECKBOX Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesionsDentition:Comments:Pulmonary/Thorax: FORMCHECKBOX Respirations regular and unlabored FORMCHECKBOX Transverse to AP ratio 2:1 FORMCHECKBOX Chest expansion symmetric FORMCHECKBOX Lungs clear to auscultation in all fields without adventitious soundsCL – Clear FORMCHECKBOX Percussion resonant throughout all lung fields, dull towards posterior bases WH – Wheezes FORMCHECKBOX Tactile fremitus bilaterally equal without overt vibrationCR - Crackles FORMCHECKBOX Sputum production: thick thin Amount: scant small moderate large RH – Rhonchi Color: white pale yellow yellow dark yellow green gray light tan brown redD – Diminished S – Stridor Ab - AbsentCardiovascular: FORMCHECKBOX No lifts, heaves, or thrills PMI felt at: Heart sounds: S1 S2 Regular FORMCHECKBOX No murmurs, clicks, or adventitious heart sounds FORMCHECKBOX No JVDRhythm (for patients with ECG tracing – tape 6 second strip below and analyze) FORMCHECKBOX Calf pain bilaterally negative FORMCHECKBOX 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: FORMCHECKBOX No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]Location of edema: ancles non-pitting FORMCHECKBOX Extremities warm with capillary refill less than 3 secondsGI/GU: FORMCHECKBOX Bowel sounds active x 4 quadrants; no bruits auscultated FORMCHECKBOX No organomegaly Liver span cm FORMCHECKBOX Percussion dull over liver and spleen and tympanic over stomach and intestine FORMCHECKBOX Abdomen non-tender to palpationUrine output: FORMCHECKBOX Clear FORMCHECKBOX Cloudy Color: Previous 24 hour output: mLs N/A FORMCHECKBOX Foley Catheter FORMCHECKBOX Urinal or Bedpan FORMCHECKBOX Bathroom Privileges without assistance or with assistance FORMCHECKBOX CVA punch without rebound tenderness Last BM: (date / / ) 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: FORMCHECKBOX Clean, moist, without discharge, lesions or odor FORMCHECKBOX Not assessed, patient alert, oriented, denies problems Other – Describe:Musculoskeletal: Full ROM intact in all extremities without crepitus FORMCHECKBOX 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] FORMCHECKBOX vertebral column without kyphosis or scoliosis FORMCHECKBOX Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesiasNeurological: FORMCHECKBOX Patient awake, alert, oriented to person, place, time, and date FORMCHECKBOX Confused; if confused attach mini mental exam FORMCHECKBOX CN 2-12 grossly intact FORMCHECKBOX Sensation intact to touch, pain, and vibration FORMCHECKBOX Romberg’s Negative FORMCHECKBOX Stereognosis, graphesthesia, and proprioception intact FORMCHECKBOX Gait smooth, regular with symmetric length of the strideDTR: [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 ±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):LabDatesTrendAnalysisTroponin9/24: 0200, 04000.07, 0.16Very abnormally high. May indicate heart damage.Creatinine9/241.6Elevated in some pts w/ unstable agina Chest X ray9/24Normal heart size\+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)Diet: 2 gram sodium. This diet is used often with heart patients.Activity: Patient has not been ambulating regularly without assistance due to unsteady gait.Chest x ray: Normal heart size, probably small left sided effusion. The osseous structures are intact.Cardiology consult has been made. 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)1. Acute pain?related to tissue ischemia secondary to arterial occlusion, tissue inflammation as evidence by pressure on patient’s chest.2. Activity intolerance?related to imbalance between oxygen supply and metabolic needs of tissues as evidence by angina when patientambulates3.4.5.± 15 CARE PLANNursing Diagnosis: . Acute pain?related to tissue ischemia… Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Goal on Day care is ProvidedChest pain is lost or controlledMonitor or record the characteristics of the pain, noted the report verbal, nonverbal cues, and the haemodynamic response (grimacing, crying, anxiety, sweating, clutching his chest, rapid breathing, blood pressure / heart frequency change).Variations in appearance and behavior, because the pain occurs as the findings of the assessment. Most of the Acute Myocardial Infarction looks sick, distraction, and focus on the pain. History of verbal and deeper investigation of the precipitating factors should be delayed until the pain is gone. Breathing may increase senagai caused pain and is associated with anxiety, stress cause temporary loss of catecholamines would increase heart rate and blood pressure.Chest pain was eliminated and the patient was able to demonstrate relaxation techniques when prompted.Able to demonstrate use of relaxation techniques.Showed reduced stress, relaxed and easy to move.±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 : No*□Dietary Consult Yes□PT/ OT: Yes□Pastoral Care No□Durable Medical Needs: No*□F/U appts: Yes *□Med Instruction/Prescription *□ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH: No□Palliative Care ± 15 CARE PLANNursing Diagnosis: . Activity intolerance?related to imbalance between oxygen supply and metabolic needs… Patient Goals/OutcomesNursing Interventions to Achieve GoalRationale for InterventionsProvide ReferencesEvaluation of Interventions on Day care is Provided-Patient states desire to increaseDiscuss with patient the need for activity.To communicate to patient that activity will improve physical and psychosocial well-beingThe importance of activity including what activities the patient enjoys were discussed and the Activity levelIdentify activities patient considers desirable and meaningful To enhance his motivation to become more active.Patient was taught some extra exercises to increase strength. -Patient states understanding ofTeach patient exercises for increasing strength and enduranceThis will improve breathing and gradually increase activity level.The patient responded positively to the suggestions. The need to increase activityLevel gradually. ± 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 : No*□Dietary Consult: Yes *□PT/ OT: Yes□Pastoral Care: No□Durable Medical Needs: No*□F/U appts : Yes*□Med Instruction/Prescription : Yes□ are any of the patient’s medications available at a discount pharmacy? □Yes □Rehab/ HH : No□Palliative Care : No ................
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