UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: J.G. |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 9/8/2015 |

| ( 1 PATIENT INFORMATION |Agency: FHT UD |

|Patient Initials: E.B. |Age:80 |Admission Date: 9/2/2015 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis: Aortic stenosis |

|Primary Language: English | |

|Level of Education: College (Bachelor’s) |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired police officer |Atrial fibrillation, Congestive heart failure, Hypertension, |

| |Hypothyroidism |

|Number/ages children/siblings: No children | |

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|Served/Veteran: No. |Code Status: Full code |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: Lives with wife in one story house |Advanced Directives: Living Will |

| |If no, do they want to fill them out? |

| |Surgery Date: None Procedure: None |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: Baptist |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: |

|“I was having shortness of breath and increasing back pain.” |

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

|The patient is an eighty year old male admitted 9/2/15 with shortness of breath and increasing back pain. The patient previously fell on 8/12/15 and admitted with |

|a T12 compression fracture, due to severe aortic stenosis, surgery was not done and patient was placed in a lumbosacral brace. The onset of pain was four to five |

|days ago, the location is his lower back, the duration is the constant, the characteristic of the pain is sharp and achy, there is no associated factors, his pain |

|medicine relives the pain, the treatments used at home were Percocet and morphine, the severity of his pain was 8/10. The patient went to a cardiologist |

|appointment and describes his symptoms of shortness of breath and back pain and referred to FHT for further evaluation. |

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

|Date |Operation or Illness |

|9/2015 |Severe aortic stenosis with transcatheter aortic valve replacement scheduled for 9/2015 |

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|( 2 FAMILY MEDICAL HISTORY |

|( 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 (10/24/2014) | | |

|Influenza (flu) (11/01/2014) | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? | | |

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

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 | |No known allergies |

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|Other (food, tape, latex, dye, | | |

|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) |

|Aortic stenosis is the most common valvular abnormality, affecting nearly 2% of adults older than 65 years of age (Huether & McCance, 2011). Aortic stenosis is |

|narrowing of the aortic valve orifice. There is a progressive narrowing of the valve orifice that makes it more difficult for the left ventricle to eject blood to |

|the aorta. As it progresses, the ventricle contracts more slowly and with more force in order to maintain a normal cardiac output. Numerous gene abnormalities have|

|been associated with aortic stenosis. The causes of aortic stenosis include congenital leaflet malformation, rheumatic endocartidits, and degenerative changes |

|associated with aging. Symptoms range from dyspnea, angina, fatigue, syncope, palpitations and can evolve into left and right heart failure. Aortic stenosis can be|

|diagnosed through a several number of tests including: an echocardiogram, EKG, chest x-ray, MRI, and exercise stress tests. Management of aortic stenosis includes|

|valve replacement with a prosthetic valve followed by long term anticoagulation therapy and prophylaxis for endocarditis as needed (Huether & McCance, 2011). After|

|the onset of symptoms of aortic stenosis, the patient’s prognosis is poor. |

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

|Name: amiodarone (Cordarone) |Concentration: 200mg/ tablet |Dosage Amount: 200mg |

|Route: PO (by mouth) |Frequency: daily |

|Pharmaceutical class: antiarrhythmias |Home Hospital or Both |

|Indication: Management of atrial fibrillation |

|Adverse/ Side effects: dizziness, fatigue, bradycardia, hypotension, congestive heart failure |

|Nursing considerations/ Patient Teaching: Monitor heart rate and rhythm throughout therapy. Teach patients to monitor pulse daily and report abnormalities. Teach |

|patients to avoid grapefruit juice during therapy. |

|Name: docusate sodium (Colace) |Concentration: 100mg/ capsule |Dosage Amount: 100mg |

|Route: PO (by mouth) |Frequency: every 12 hours |

|Pharmaceutical class: stool softeners |Home Hospital or Both |

|Indication: Prevention of constipation |

|Adverse/ Side effects: mild cramps, diarrhea |

|Nursing considerations/ Patient Teaching: Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Administer with a full |

|glass of water or juice. Encourage patients to increase fluid intake, bulk in the diet and mobility. |

|Name: levothyroxine (Synthroid) |Concentration: 75mcg/tablet |Dosage Amount: 75mcg |

|Route: PO (by mouth) |Frequency: daily |

|Pharmaceutical class: thyroid preparations |Home Hospital or Both |

|Indication: Thyroid supplementation in hypothyroidism |

|Adverse/ Side effects: headache, abdominal cramps, heat intolerance, weight loss |

|Nursing considerations/ Patient Teaching: Administer with a full glass of water before breakfast. Teach patient to take medication as directed at the same time |

|each day. |

|Name: metoprolol (Lopressor) |Concentration: 25mg/tablet |Dosage Amount: 25mg |

|Route: PO (by mouth) |Frequency: twice a day |

|Pharmaceutical class: beta blockers |Home Hospital or Both |

|Indication: Hypertension, management of stable symptomatic heart failure. |

|Adverse/ Side effects: fatigue, weakness, dizziness, bradycardia, pulmonary edema, hypotension, erectile dysfunction |

|Nursing considerations/ Patient Teaching: Monitor blood pressure, ECG, and pulse frequently. Teach patient to take medication as directed at the same time each |

|day. Do not skip doses or abruptly stop taking medications. Teach patient and family to check pulse and BP. Notify health care professional if slow pulse, |

|difficulty breathing, or wheezing occurs. |

|Name: simvastatin (Zocor) |Concentration: 40mg/tablet |Dosage Amount: 40 mg |

|Route: PO (by mouth) |Frequency: daily at bedtime |

|Pharmaceutical class: HMG COA reductase inhibitors |Home Hospital or Both |

|Indication: Management of primary hypercholesterolemia |

|Adverse/ Side effects: abdominal cramps, constipation, diarrhea, flatus, heartburn, rhabdomyolysis |

|Nursing considerations/ Patient Teaching: Avoid grapefruit and grapefruit juice. Notify health care provider if unexplained muscle pain, tenderness, or weakness |

|occurs. |

|Name: morphine sulfate ER (MS Contin) |Concentration: 15mg/tablet |Dosage Amount: 15 mg |

|Route: PO (by mouth) |Frequency: every 12 hours |

|Pharmaceutical class: opioid agonists |Home Hospital or Both |

|Indication: management of moderate to severe chronic pain |

|Adverse/ Side effects: confusion, sedation, hypotension, constipation, respiratory depression |

|Nursing considerations/ Patient Teaching: Assess type, location, and intensity of pain. Teach patient to avoid the use of alcohol or other CNS depressants while on|

|this medication. |

|Name: albuterol sulfate 2.5mg + ipratropium bromide 0.5mg|Concentration: 3mg/3ml |Dosage Amount: 3ml |

|(Duoneb) | | |

|Route: inhalation (nebulizer) |Frequency: every 4 hours as needed |

|Pharmaceutical class: bronchodilators |Home Hospital or Both |

|Indication: Prevent bronchospasms, treat symptoms of shortness of breath |

|Adverse/ Side effects: headache, dizziness, nausea, and dry mouth |

|Nursing considerations/ Patient Teaching: Teach patient to take as directed, if the medication does not help with bronchospasm notify health care provider. |

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

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

|Diet patient follows at home? “Whatever my wife makes.” |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |The patient’s total calorie intake exceeded the target amount, 2753/2220. The |

| |amount of carbohydrates in the patient’s diet met the target amount at 44% of |

| |calories. The amount of protein in the diet met the target amount at 20% of |

| |calories. The total fat in the patient’s diet exceed the target amount at 39%. An|

| |increased amount of fat in the patient’s diet is not ideal for the patient’s |

| |diagnosis of hypertension. The amount of cholesterol exceeds the target amount at|

| |844mg, the target amount is less than 300 mg. The patient is currently has |

| |hypercholesterolemia so the increase of cholesterol in his diet affects how well |

| |his medication can be effective. The patient’s calcium and potassium intake is |

| |below the target amount. Increasing dietary potassium is important for the |

| |patient because hypokalemia can cause cardiac arrhythmias. Educating the patient |

| |about foods rich in potassium is vital. The amount of sodium in the patient’s |

| |diet is over the target amount at 5837mg, the target amount is 1500 mg. The |

| |increased amount of sodium affects how well his hypertension is managed. |

| |Educating the patient about how to decrease his sodium intake is imperative. |

|Breakfast: | |

|French toast (2 slices) | |

|Lite pancake syrup | |

|1 scrambled egg | |

|2 slices of turkey bacon | |

|One cup of cranberry juice | |

|Lunch: | |

|2 cup of Baked ziti with meat sauce (ground beef and Prego) | |

|Herbed green beans | |

|1 can of Diet Dr. Pepper | |

|Dinner: | |

|1 thigh of Baked chicken | |

|2 cups of Macaroni and cheese | |

|1 cup of String beans | |

|Snacks: | |

|Fruit salad with no dressing | |

|2 cups of trail mix | |

|Liquids (include alcohol): | |

|6 cups of water | |

|[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 a 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 like to stay to myself and read”. |

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

|“Nope.” |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|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.” |

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|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?  “By my mother, when I was a kid.” |

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|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?  ______________________ |

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|Are you currently in a safe relationship? “Yes, very safe.” |

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|( 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. Self 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: |

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

|Ego integrity vs. despair- as people become senior citizens, they slow down productivity and explore life as a retired person. It is common to contemplate |

|accomplishments and is able to develop integrity if we feel like we lead a successful life. If not, we can see our lives as unproductive, or feel like we did not |

|accomplish our goals, we develop despair which can lead to depression and hopelessness. Success in this stage will lead to the virtue of wisdom (Nevid, 2011, |

|p.396). Wisdom enables a person to look back on their life with a sense of closure and completeness, and also accept death without fear. |

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

|While speaking to the patient during the interview, he expressed ego integrity. He enjoys his retirement and spending time with his wife. When he spoke about his |

|current hospitalization he displayed both ego integrity and despair. Despair was displayed because he did not know exactly what would happen with his condition and|

|his upcoming surgery, but he displayed ego integrity because he had confidence that he would be okay and that he would be going to rehab to become stronger so that|

|he can go home to his wife. |

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|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|“My diet over the years”. |

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|What does your illness mean to you? |

|“It means that I am getting older and I should have taken better care of my body.” |

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|+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” |

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|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? “Yes, chlamydia.” |

|Have you or a partner ever had an abnormal pap smear? “No, not that I know of.” |

|Have you or your partner received the Gardasil (HPV) vaccination? “No.” |

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|Are you currently sexually active?  “No.” If yes, are you in a monogamous relationship? N/A When sexually active, what measures do you take to prevent acquiring a|

|sexually transmitted disease or an unintended pregnancy?  N/A |

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|How long have you been with your current partner? “58 years” |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  “My shortness of breath.” |

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|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?

“It is important, I know God is watching me and guiding my steps.”

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Do your religious beliefs influence your current condition?

“No it does not.”

|+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? X years |

| | |(age thru ) |

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

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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? |

| |If yes, what did they use to try to quit? |

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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

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

| |Volume: |(age thru ) |

| |Frequency: | |

| If applicable, when did the patient quit? | | |

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|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 ) |

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

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

|“No, not that I am aware of.” |

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|5. For Veterans: Have you had any kind of service related exposure? |

|N/A |

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( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | 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: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: 1x.daily |Appendicitis | Enlarged lymph nodes |

|Other: Left foot wound (0.5cm x0.5cm) | Abdominal Abscess |Other: |

|Be sure to answer the highlighted area | Last colonoscopy? 01/2014 | |

|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: 4x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

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

| Routine dentist visits 1x/year | | Hypothyroid /Hyperthyroid |

|Vision screening | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

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|Pulmonary | | |

| Difficulty Breathing (at times) | |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? 9/2/15 | 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? 1/2014 | Anxiety |

|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? 9/8/15 (continuous) |Arthritis | Chicken Pox |

|Other: |Other: T12 compression fracture |Other: |

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|General Constitution |

|Recent weight loss or gain |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|“Nope.” |

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|Any other questions or comments that your patient would like you to know? |

|“No.” |

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|±10 PHYSICAL EXAMINATION: |

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|General Survey: alert and oriented x3, pleasant, able to make his needs known. |

|Height: 6’1 |

|Weight 213 lbs |

|BMI: 28.1(overweight) |

|Pain: (include rating and location) |

|1/10 |

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|Pulse: 56 |

|Blood Pressure: (include location) |

|109/63 (right arm) |

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|Respirations: 15 |

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|Temperature: (route taken?) 97.5 F (oral) |

|SpO2: 98 |

|Is the patient on Room Air or O2: Room Air |

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

| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |

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

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

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

| clear, crisp diction |

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|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 |

|If anything is not checked, then use the blank spaces to Left foot wound between 1st and 2nd toe |

|describe what was assessed in the physical exam that |

|was not WNL (within normal limits) |

| Central access device Type: peripheral line Location: Right wrist Date inserted: 9/2/2015 |

|Fluids infusing? no yes - what? |

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|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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 8 inches & left ear- 8 inches |

| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |

|Dentition: has full dentures to the bottom |

|Comments: |

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

|Percussion resonant throughout all lung fields, dull towards posterior bases |

|Sputum production: thick thin Amount: scant small moderate large |

|Color: white pale yellow yellow dark yellow green gray light tan brown red |

|Lung sounds: |

|RUL: CL LUL:CL |

|RML:CL LLL:CL |

|RLL:CL |

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|CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent |

|Cardiovascular: No lifts, heaves, or thrills |

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|Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD |

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

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|Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding] |

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|Apical pulse: Carotid: Brachial: Radial:3+ Femoral: Popliteal:2+ DP: PT: |

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|No temporal or carotid bruits Edema: [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |

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|Location of edema: pitting non-pitting |

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|Extremities warm with capillary refill less than 3 seconds |

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|GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly |

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

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|Last BM: (date 9 / 6 / 2015 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

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|Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red |

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|Nausea emesis Describe if present: |

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|Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems |

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|Other – Describe: |

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

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

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|CVA punch without rebound tenderness |

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

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|Strength bilaterally equal at 4 RUE 4 LUE 3 RLE & 3 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] |

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|vertebral column without kyphosis or scoliosis |

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

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

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

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|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |

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|DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus] |

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|Triceps: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: |

|positive negative |

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|±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. |

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|Lab |

|Dates |

|Trend |

|Analysis |

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|Chest x-ray |

|09/02/2015 |

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|Stable cardiomegaly with no acute cardiopulmonary process. |

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|B-type naturietic peptide |

|685 |

|Normal level (0-100pg/mL) |

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|09/06/2015 |

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|There was no trend this lab was drawn one time. |

|It primarily used to help detect, diagnose, and evaluate the severity of heart failure. BNP levels below 100 pg/mL indicate no heart failure. BNP levels above 600 |

|pg/mL indicate moderate heart failure. |

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|Transthoracic echocardiogram |

|09/03/2015 |

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|The left ventricle was moderately dilated. Systolic function was moderately reduced. Ejection fraction was estimated to be 40%. An ejection fraction of 40% indicates|

|that is below normal but not indicative of heart failure. An ejection fraction of 40% indicates heart failure. In the aortic valve, there was severe aortic stenosis |

|with mild to moderate regurgitation. The valve mean gradient was 45 mmHg. Any level over 12mmHg is indicative of severe stenosis. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing, multidisciplinary treatments and procedures, such as diet, vitals, activity, |

|scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.) |

|Activity as tolerated- The patient can get short of breath so activities should be timed. Low sodium diet- due to his HTN and CHF. Zinc oxide topical (1 application |

|to left toe wound). Daily weights- to monitor for fluid overload. |

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

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|1. Ineffective breathing pattern r/t fatigue and decreased lung expansion AEB dyspnea |

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|2. Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia |

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|3.Risk for ineffective tissue perfusion related to decreased cardiac output |

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|4.Pain r/t injury to T12 AEB reports of pain |

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|5. Risk for excess fluid volume r/t compromised regulatory mechanism. |

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|6. Activity intolerance r/t imbalance of O2 supply and demand |

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± 15 CARE PLAN

Nursing Diagnosis: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

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

| | |Provide References | |

|Patient will maintain adequate cardiac output as |Monitor vital signs frequently as needed. |Vital signs are monitored so |On the patient’s day of discharge, the patient |

|evidenced by strong peripheral pulses, systolic BP | | |maintained adequate cardiac output. Systolic BP is |

|within 20 mm Hg of baseline, HR 60 to 100 beats/min | | |109/63, HR slightly low at 56 with sinus rhythm. |

|with regular rhythm, urinary output greater than 30 | | |Patient urinated 40ml/hr using urinal. Patient’s skin|

|mL/hr, warm and dry skin, and normal level of | | |warm and dry and the patient is alert and oriented |

|consciousness by discharge. | | |x3. |

| |Monitor results of laboratory and diagnostic tests. |Results of the test provide clues to the status of | |

| | |the disease and response to treatments. | |

| |Monitor oxygen saturation. |Provides information regarding the heart’s ability to| |

| | |perfuse distal tissues with oxygenated blood. | |

| |Monitor response to medications to control blood |These medications are useful to optimize cardiac | |

| |pressure. |function including blood pressure, heart rate, | |

| | |myocardial oxygen demand, intravascular fluid volume | |

| | |and cardiac rhythm. (Ackley, 2014,) | |

| |Monitor intake and output. |Decreased cardiac output results in decreased | |

| | |perfusion of kidneys, resulting in decreased urine | |

| | |output. (Ackley, 2014) | |

| |Observe skin color, moisture, temperature, and |Presence of pallor; cool, moist skin; and delayed | |

| |capillary refill time. |capillary refill time may be due to peripheral | |

| | |vasoconstriction or reflect cardiac decompensation | |

| | |and decreased output. (Ackley, 2014) | |

| |Note changes in orientation: lethargy, confusion, |It may indicate inadequate cerebral perfusion | |

| |disorientation, anxiety, and depression. |secondary to decreased cardiac output. | |

|The patient will participate in activities that will |Encourage periods of rest and assist with all |Anti-ischemic therapy includes minimizing myocardial |The patient participated in activities that reduced |

|reduce the workload of the heart throughout entire |activities. |oxygen demand. |the workload of the heart throughout hospital stay to|

|hospital stay to discharge | | |discharge. |

| |Instruct patient to get adequate bed rest and sleep. |To promote relaxation to the body. | |

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|Include a minimum of one | | | |

|Long term goal per care plan | | | |

|±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 |

|X PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|X F/U appointments |

|X Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? X Yes: Metoprolol 25mg |

|X Rehab/ HH |

|□Palliative Care |

± 15 CARE PLAN

Nursing Diagnosis: Ineffective breathing pattern r/t fatigue and decreased lung expansion AEB dyspnea

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

| | |Provide References | |

|Patient will report the ability to breathe |Monitor respiratory rate, depth, and ease of |Increased rate and deep labored breathing indicates |The patient stated “I feel like my breathing is fine,|

|comfortably by the end of shift. |respiration. |that the patient is having difficulty breathing. |I don’t have any difficulty breathing”. The patient’s|

| | | |respiratory rate is 16 and it is even and unlabored. |

| |Instruct client to deep breathe or use incentive |Deep breathing and the incentive spirometer promotes | |

| |spirometer every 1 - 2 hours |lung expansion. | |

|  |Maintain HOB elevation at least 30 degrees. |Allows for better chest expansion, thereby improving | |

| | |pulmonary capacity. | |

| |Assist patient to use relaxation techniques. |Reduces muscle tension, decreases work of breathing. | |

| | | | |

|Client will have exhibited signs of adequate |Monitor pulse oximetry for oxygen saturation and |Oximetry readings of 90 correlate with PaO2 of 60. |The patient’s O2 saturation remained in the range of |

|perfusion throughout hospital stay to discharge. |notify for < 90% |Levels below this do not allow for adequate perfusion|94-97% on room air and on 2L/in via n/c the |

| | |to tissues and vital organs. |saturations ranged from 96-99% |

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|Include a minimum of one | | | |

|Long term goal per care plan | | | |

|±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 |

|X Dietary Consult |

|X PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|X F/U appointments |

|X Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? X Yes □ No |

|X Rehab/ HH |

|□Palliative Care |

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed., pp. 179-181, 187, 189,). United States: Mosby, an imprint of Elsevier Inc.

Huether, S. E. , and K. L. McCance. Understanding Pathophysiology. (5th ed. 2012. pp. 785,788). United States: Mosby

Nevid, J. (2011). Psychology: Concepts and applications (3rd ed., pp. 396-398). Boston: Houghton Mifflin.

Nursing Central by Unbound Medicine. (2015). (ver. 1.610.627) [Mobile Application Software] Retrieved from



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