UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Mackenzie Kemp |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 10/17/14 |

| ( 1 PATIENT INFORMATION |Agency: Bayfront Medical Center |

|Patient Initials: J.H. |Age: 74 years old |Admission Date: 10/16/14 |

|Gender: female |Marital Status: widowed |Primary Medical Diagnosis |

|Primary Language: English |Pulmonary Edema |

|Level of Education: Associate’s Degree in Secretarial Science |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired medical records clerk at a nursing home | |

|Number/ages children/siblings: | |

|2 sons: age 48 and 51. No siblings. | |

|Served/Veteran: |Code Status: FULL CODE |

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

|Living Arrangements: |Advanced Directives: yes |

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

|Lives by self in a one story house in St. Petersburg. Able to perform ADLs without |Surgery Date: n/a Procedure: |

|assistance. Uses a handyman for some things that she needs help with. Denies history of | |

|falls. | |

|Culture/ Ethnicity /Nationality: Caucasian | |

|Religion: Protestant |Type of Insurance: Medicare, TriCare for Life |

|( 1 CHIEF COMPLAINT: |

|Patient states that she “could barely breathe”. |

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

|Patient is a 74 year old female who presented to the ED on 10/16/2014 with difficulty breathing. She states that this began mildly about 5 days prior but had been |

|worsening and was severe when she came to the ED. The wheezing and difficulty breathing was reportedly made worse by lying flat. It was relieved with a CPAP |

|machine and 3 sublingual nitroglycerin tablets. Patient also reports a history of occasional dyspnea upon exertion over the past three months. Patient denied |

|cough, hemoptysis, and hematemesis. On arrival, patient had chest imaging consistent with vascular congestion and a BNP level of 1789. An electrocardiogram also |

|showed an EF of 30.7%. She was given Lasix in the ED with some symptom improvement. Patient was admitted to the med-tele floor 4S for continued monitoring and |

|diuresis with Lasix. |

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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 |

|July 2011 |Paroxysmal atrial fibrillation status post DC cardioversion |

|July 2011 |Non Q wave myocardial infarction |

|July 2011 |Hypertrophic Cardiomyopathy w/o obstruction |

|July 2011 |Hypertension |

|July 2011 |Congestive Heart Failure |

|Unknown |Osteoporosis |

|Unknown |Hyperlipidemia |

|Unknown |Diet controlled diabetes |

|Unknown |Iron deficiency anemia |

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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 (Date) Is within 10 years? | | |

|Influenza (flu) (Date) Is within 1 years? | | |

|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 |Sulfa drugs |Rash. Trouble breathing. |

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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) |

|Pulmonary edema is the unusual accumulation of fluid in the lungs which leads to shortness of breath. Pulmonary edema most often develops as a result of heart |

|failure (evident in this case from the BNP of 1789). Severe left ventricular failure decreases the effectiveness of the heart’s ability to pump blood to the rest |

|of the body. This causes pressure to build inside the left atrium, the pulmonary veins, and the capillaries within the lungs. As the pressure increases, fluid is |

|forced into the alveoli where oxygen is usually exchanged. Fluid within the alveoli interferes with normal oxygenation in the lungs and results in shortness of |

|breath. Symptoms of pulmonary edema may include hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, crackles or wheezing with breathing, problems speaking in full|

|sentences due to shortness of breath, anxiety, restlessness, edema in legs, and diaphoresis. Diagnosis includes a thorough exam, beginning with auscultation of |

|heart and lung sounds, listening for abnormal heart sounds, tachycardia, tachypnea, and crackles in the lungs. The physician will also note leg or abdominal edema,|

|swelling of neck veins, and pallor or cyanosis. Possible diagnostic tests may include a blood chemistry, pulse oximetry, arterial blood gases, chest x-ray, |

|complete blood count, echocardiogram, and electrocardiogram. An immediate chest x-ray would show interstitial edema and is typically diagnostic. Measurement of |

|serum BNP levels which are elevated in heart failure also help if the diagnosis is in doubt. Pulmonary edema is usually treated in the emergency room with |

|immediate oxygenation via a face mask or nasal cannula. In severe cases a mechanical ventilator may be necessary to assist with respirations. Nitroglycerin and |

|diuretics such as furosemide (Lasix) are commonly prescribed to reduce preload. Afterload reducers such as nitroprusside may also be used to dilate vessels and |

|reduce pressure on the left ventricle. Blood pressure medications such as ACE inhibitors may also be used to control hypertension if present. The prognosis of |

|pulmonary edema varies depending on the severity of heart failure. The condition may improve quickly or slowly. Some people may need to use a breathing machine for|

|a long time. If not treated in time, it can be fatal. Prevention of pulmonary edema is dependent on controlling heart failure with prescribed medications and a |

|healthy low-salt, low-fat diet (Chen, 2014). |

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

|Name Carvedilol (Coreg) |Concentration 25mg=1 tab |Dosage Amount 1 tab |

|Route PO |Frequency BID |

|Pharmaceutical class beta blockers |Home Hospital or Both |

|Indication hypertension and heart failure |

|Adverse/ Side effects dizziness, fatigue, weakness, BRADYCARDIA, HEART FAILURE, PULMONARY EDEMA, STEVENS-JOHNSON SYNDROME |

|Nursing considerations/ Patient Teaching monitor blood pressure and pulse frequently. Monitor I&O and daily weights. |

|Name Enoxaparin (Lovenox) |Concentration 40mg=0.4ml |Dosage Amount 0.4 ml |

|Route SQ |Frequency daily |

|Pharmaceutical class antithrombotics. |Home Hospital or Both |

|Indication prevent ion of venous thromboembolism (VTE) and deep vein thrombosis (DVT) |

|Adverse/ Side effects bleeding, anemia, thrombocytopenia |

|Nursing considerations/ Patient Teaching assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black tarry stools; hematuria) |

|Name Furosemide (Lasix) |Concentration 40mg=1 tab |Dosage Amount 1 tab |

|Route PO |Frequency BID |

|Pharmaceutical class loop diuretics |Home Hospital or Both |

|Indication edema due to heart failure |

|Adverse/ Side effects hypotension, erythema multiforme, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROSIS, dehydration, hypokalemia and other electrolyte |

|imbalances |

|Nursing considerations/ Patient Teaching assess fluid status, monitor daily weight and I& O, monitor BP and pulse before and during administration, assess patient |

|for skin rash |

|Name Lisinopril |Concentration 20mg=1 tab |Dosage Amount 1 tab |

|Route PO |Frequency BID |

|Pharmaceutical class ace inhibitors |Home Hospital or Both |

|Indication management of hypertension and heart failure |

|Adverse/ Side effects dizziness, cough, hypotension, ANGIOEDEMA |

|Nursing considerations/ Patient Teaching monitor BP, pulse, weight, assess for signs of angioedema (facial swelling, dyspnea) |

|Name Pantoprazole (Protonix) |Concentration 40mg= 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency daily |

|Pharmaceutical class proton pump inhibitors |Home Hospital or Both |

|Indication GI prophylaxis- ulcer prevention |

|Adverse/ Side effects PSEUDOMEMBRANOUS COLITIS, hyperglycemia, hypomagnesaemia, abdominal discomfort |

|Nursing considerations/ Patient Teaching assess patient regularly for epigastric or abdominal pain and for blood in stool or emesis |

|Name Pravastatin |Concentration80mg= 1 tab |Dosage Amount 1 tab |

|Route PO |Frequency HS (at bedtime) |

|Pharmaceutical class hmg coa reductase inhibitors (statins) |Home Hospital or Both |

|Indication management of primary hypercholesterolemia |

|Adverse/ Side effects abdominal cramps, constipation, diarrhea, heartburn, rash, RHABDOMYOLYSIS |

|Nursing considerations/ Patient Teaching if patient develops muscle tenderness during therapy, CPK levels should be monitored. If CPK levels are markedly elevated |

|or myopathy occurs, therapy should be discontinued. |

|Name Spironolactone |Concentration 25mg=1 tab |Dosage Amount 1 tab |

|Route PO |Frequency daily |

|Pharmaceutical class potassium-sparing diuretics |Home Hospital or Both |

|Indication management of edema associated with HF |

|Adverse/ Side effects hyperkalemia, DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS |

|Nursing considerations/ Patient Teaching monitor I&O and daily weights, evaluate BP before administration, assess patient frequently for development of |

|hyperkalemia, assess patient frequently for skin rash. |

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

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

|Diet patient follows at home? Diabetic diet. Low sugar. |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |The patient is already on a low sugar diabetic diet at home and will need to |

| |consider following a low sodium diet as well now based on her diagnosis of |

| |congestive heart failure. |

|Breakfast: 1 banana. Decaffeinated coffee with stevia |Congestive heart failure can be improved with an appropriate diet that is low in |

| |sodium and fat. Recommendations to reduce the sodium content in one’s diet |

| |include: eating plenty of fruits and vegetables, choosing low-salt foods such as |

| |fresh meats, poultry, fish, legumes, eggs, milk, yogurt, plain rice, pasta, and |

| |oatmeal. Food labels should always be read before buying packaged food. Sodium |

| |intake should be limited to 2,000 milligrams a day or less (Diet, 2014). |

| 1 Kashi granola bar. |According to My Plate the patient should eat about 1 ½ cups of fruit and 2 cups |

| |of vegetables daily. The patient currently reports eating one serving of each a |

| |day and could increase this by adding one additional fruit and vegetable per day.|

| |5 ounces of grains (atleast half being whole grains) are also recommended per |

| |day. The patient does eat a Kashi granola bar which includes whole grains (but |

| |need to keep eye on sodium content of packaged foods) but could stand to add more|

| |choices to her diet such as rice and pasta. 5 ounces of lean protein are also |

| |recommended daily. The patient reports eating a burger and chicken nuggets for |

| |protein. However these contain surprising amounts of sodium and healthier |

| |alternatives such as fresh poultry or fish are recommended to reduce sodium |

| |content. 3 cups of dairy are recommended daily. The patient did not report any |

| |dairy other than a vanilla icecream cone from McDonalds which isn’t very healthy |

| |nd contains hidden sodium as well. My recommendation would be to consume a glass |

| |or two of milk a day and a cup of yogurt with breakfast. |

|Lunch: McDonalds quarter pounder deluxe. |Overall, the is maintaining the diabetic diet relatively well but now needs to |

| |consider replacing high sodium meals like the Mcdonalds lunch with healthier, |

| |low-sodium alternatives (ChooseMyPlate, 2014). |

|Vanilla icecream cone. Water. | |

|Dinner: 1 serving of meat like Purdue chicken nuggets (4). | |

|1 serving of vegetables like carrots or squash. Sugar free/caffeine free ice tea-| |

|1 glass. | |

|Snacks:1 piece of chocolate a day. (Bliss dark chocolate) | |

|A handful of nuts (almonds, walnuts) | |

|Liquids (include alcohol): | |

|1 can of diet coke or diet sierra mist. 2-3 glasses of water a day. 1 glass of | |

|tea. | |

|[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? |

|Patient states: “I help myself.” Once in a while she calls on her cousin who lives nearby. |

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

|Patient states: “I eat”, “I might have a bigger dessert than I should.” |

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

|Patient states that she does occasionally feel depressed, anxious, and overwhelmed. She likes living in her own house but admits that she does feel alone sometimes|

|since her son recently moved from Florida to North Carolina. |

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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?  ______no____ |

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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? |

|Patient is not currently in a relationship |

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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: |

|During the Ego-Integrity stage, seniors are expected to contemplate their accomplishments and develop integrity if one sees oneself as having lived a successful |

|life. Success in this stage, according to Erikson, leads to the virtue of wisdom, where one can look back on one’s life with a sense of closure and completeness |

|and accept death without fear. Meanwhile, those who look back and view their lives as unproductive or feel a sense of guilt or failure will become dissatisfied |

|and develop feelings of despair, depression, and hopelessness (McLeod, 2008). |

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

|The patient is 74 years old and is in the ego-integrity stage Throughout our interview the patient expressed pride in her children and grandchildren and all their |

|accomplishments. She also talked with pride about her years of work and time spent with her husband. She seemed optimistic about life and her accomplishments and |

|did not express any feelings of regret or disappointment to me. |

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

|It was not evident that the diagnosis of pulmonary edema had any effect on the patient’s developmental stage. |

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|+3 CULTURAL ASSESSMENT: |

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

|The patient believes in medical reasons as the cause of her illness, especially citing the history of heart problems that runs in her family. |

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|What does your illness mean to you? |

|The patient states that the illness means “I have to pace myself and try not to put myself in any danger.” |

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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? _____men____________________________________________________ |

|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? ___________________________________________ |

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|Are you currently sexually active?   ____________no___________ If yes, are you in a monogamous relationship? ____________________ When sexually active, what |

|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  __________________________________ |

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|How long have you been with your current partner? not currently with anyone. Was married for 48 years._________________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  _____n/a_________________ |

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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?

Patient states that she is an active member of her church. She prays a lot and belongs to several Christian Women’s groups. She views spirituality as a very important part of her life.

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 No |

| If so, what? |How much?(specify daily amount) |For how many years? 0 years |

|n/a |n/a |(age n/a thru ) |

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

| | |n/a |

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

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

|no |

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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? |

|Patient reports that she used to drink wine but does not |Volume: 1 glass. |(age 18 thru 60 ) |

|anymore. | | |

| |Frequency: Just socially, every few months. | |

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

|At least 10 years ago. |

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

| If so, what? |

|n/a |How much? |For how many years? |

| |n/a |(age n/a thru ) |

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

| |n/a | |

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

|Not that the patient knows 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- age related loss of | GERD Cholecystitis | Fever |

|elasticity | | |

| 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: 30 | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: shower 2-3 times a week and as needed|Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

| | Last colonoscopy? 2011 | |

|HEENT |Other: cholecystectomy 2004 |Hematologic/Oncologic |

| Difficulty seeing -astigmatism |Genitourinary | Anemia iron deficiency anemia |

| Cataracts or Glaucoma – cataracts starting | 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: x/day |Other: |

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

| Dental problems – receding gums,bridges | |Metabolic/Endocrine |

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

| Routine dentist visits 3 x/year | | Hypothyroid /Hyperthyroid |

|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- oak trees | menarche age? 13 | Encephalitis |

|last CXR? 10/16/14 | menopause age? Total hysterectomy in 1983 | Meningitis |

|Other: |Date of last Mammogram &Result: 2013 |Other: |

| |Date of DEXA Bone Density & Result: 2010 osteopenia | |

| |left hip and spine | |

|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? | 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? 2010 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|General Constitution |

|Recent weight loss or gain –patient denies |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? “It could be better, if I have a problem I try to work with the doctor to straighten it out.” |

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

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|No. |

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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: |

|Patient is a pleasant 74 year old, slightly overweight female. |

|Height 5’1” |

|Weight 151 |

|BMI 28.5 |

|Pain: (include rating and location) |

|0 |

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|Pulse 64 |

|Blood Pressure: (include location) |

|144/68 right upper arm |

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|Respirations 17 |

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|Temperature: (route taken?) |

|SpO2 99 |

|Is the patient on Room Air or O2 |

|3L nasal cannula |

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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 |

| Peripheral IV site Type: 20 gauge Location: left antecubital Date inserted: 10/16 |

|Fluids infusing? no yes - what? |

| |

|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 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

| Ears symmetric without lesions or discharge Whisper test heard: right ear- 3 inches & left ear- 3 inches |

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

|Dentition: Patient has receding gums and several bridges. |

|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 D |

|RLL D |

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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) Sinus rhythm with bundle branch block |

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|[pic] |

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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: 2 Carotid: 2 Brachial: 2 Radial: 2 Femoral: 2 Popliteal: 2 DP: 2 PT: 2 |

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

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|Location of edema: bilateral legs 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 10 / 16 / 2014 ) 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: yellow Previous 24 hour output: 2150 mLs N/A |

| |

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

| |

|CVA punch without rebound tenderness |

| |

| |

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

| |

|Strength bilaterally equal at __4_ RUE _4__ LUE _4__ RLE & 4___ 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] |

| |

|vertebral column without kyphosis or scoliosis |

| |

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

| |

| |

| |

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

| |

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

| |

|Stereognosis, graphesthesia, and proprioception intact 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: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 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): |

| |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|RBC |

|3.98 |

| |

|3.77 |

|Normal (3.71-5.31) |

| |

|(10/16/2014) |

| |

|(10/17/2014) |

|The red blood cell count has decreased over the past day since time of admission. |

|Levels are still within the normal limit. They are towards the bottom end of the limit because patient states she has “iron-deficiency anemia”. |

| |

|Hematocrit |

|37.9 |

| |

|35.1 |

|Normal (34-46) |

| |

|(10/16/2014) |

| |

|(10/17/2014) |

|The hematocrit level has decreased slightly since the time of admission yesterday. |

|Levels remain within normal limits. |

| |

|Platelets |

|152 |

| |

|126 L |

|Normal (150-450) |

| |

|(10/16/2014) |

| |

|(10/17/2014) |

|The platelet count has decreased since time of admission yesterday. Platelet count was normal upon admission on 10/16, but is low on 10/17. |

|While it is low, this is not a dangerous platelet count and is to be expected since the patient was put on Lovenox at the hospital to prevent blood clots. |

| |

|Glucose |

| |

| |

|137 H |

|Normal (60-100) |

| |

| |

| |

|10/17/2014 |

|Data was only available on 10/17. This blood glucose is slightly high but the patient states it is normal for her. |

|Patient is a “diet-controlled” diabetic. A level of 137 is not a cause for concern as long as the patient is managing her diabetes well and is asymptomatic. |

| |

|BNP |

|1,789.0 H |

| |

| |

|Normal (95% on room air by |same scale and type of clothing at same time each |volume(Ackley, 2011). | |

|time of discharge. |day, preferably before breakfast. | | |

| |Monitor intake and output; note trends reflecting |Accurately measuring intake and output is important |Patient maintained 99-100% oxygenation on 3L nasal |

| |decreasing urine output in relation to fluid intake. |for the client with fluid volume overload(Ackley, |cannula. |

| | |2011). | |

| |Monitor vital signs; note decreasing blood pressure, |Heart failure results in decreased cardiac output and|Patient reported that her ankles appeared less |

| |tachycardia, and tachypnea. |decreased blood pressure. Tissue hypoxia stimulates |edematous than yesterday. |

| | |increased heart and respiratory rates(Ackley, 2011). | |

| |Listen to lung sounds for crackles, monitor |Pulmonary edema results from excessive shifting of |By end of day, physician discontinued nasal cannula |

| |respirations for effort, and determine the presence |fluid from the vascular space into the pulmonary |oxygen and patient was breathing fine on room air |

| |and severity of orthopnea. |interstitial space and alveoli, resulting in dyspnea |with 96% O2 sat. |

| | |and orthopnea(Ackley, 2011). | |

| |Provide a restricted-sodium diet as appropriate. |Restricting the sodium in the diet will favor the | |

| | |renal excretion of excess fluid. Take care to avoid | |

| | |hyponatremia(Ackley, 2011). | |

| |Administer prescribed diuretics as appropriate; check|Clinical practice guidelines on heart failure site | |

| |blood pressure before administration to ensure is |that monitoring I&Os is useful for monitoring side | |

| |adequate. If IV administration, note and record urine|effects of diuretic therapy(Ackley, 2011). | |

| |output following the dose. | | |

| |Monitor for side effects of diuretic therapy; |Observe for hyperkalemia in clients receiving | |

| |orthostatic hypotension, hypovolemia, and electrolyte|potassium-sparing diuretic, especially with the | |

| |imbalances. |concurrent administration of an ACE inhibitor(Ackley,| |

| | |2011). | |

|Patient will verbalize understanding of causative |Assess client and family knowledge of disease process|It is important that the patient understand the cause|Patient listened actively as I explained the |

|factors and demonstrate behaviors to resolve excess |causing excess fluid volume. Teach about disease |of her disease and how this may affect her body with |causative factors and treatment for excess fluid |

|fluid volume by the end of my shift. |process and complications of excess fluid volume, |excess fluid volume so she can prevent further |volume. She verbalized understanding back to me. |

| |including when to contact physician. |complications | |

|Patient will demonstrate understanding of medications|Assess client and family knowledge about medical |Assistance with integration of cultural values, | |

|and CHF regimen by end of my shift as evidenced by |regimen, including medications, diet, rest, and |especially those related to foods, with medical | |

|patient verbalizing information learned back to the |exercise. |regimen promotes compliance and decreases risk of | |

|nurse. | |complications. | |

| |Teach and reinforce knowledge of medications. |Taking OTC medications without consulting the | |

| |Instruct the client not to use over the counter |physician may result in adverse drug interactions and| |

| |medications without first consulting the physician, |side effects. | |

|±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 |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|*F/U appointments |

|*Med Instruction/Prescription |

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

|□Rehab/ HH |

|□Palliative Care |

Nursing Diagnosis: Decreased cardiac output related to altered heart rate and rhythm as evidenced by bradycardia.

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

| | |Provide References | |

|Patient will display vital signs within acceptable |Administer oxygen as needed per physician’s order. |Clinical practice guidelines cite that oxygen should |Patient’s vital signs(respirations, O2sat, heart |

|limits by end of shift. |Supplemental oxygen increases oxygen availability to |be administered to relieve symptoms related to |rate) remained within limits throughout my shift. |

| |the myocardium. |hypoxemia (Ackley, 2011). |Blood pressure however was elevated as consistent |

| | | |with patient diagnosis of hypertension. |

|Patient will report decreased episodes of dyspnea or |Place client in a semi-fowlers or high fowler’s |Elevating the head of the bed and legs in down |Patient denied dyspnea and angina throughout my |

|angina by end of shift. |position with legs down or in a position of comfort. |position may decrease the work of breathing (Ackley, |shift. |

| | |2011). | |

|Patient will participate in activities that reduce |Observe for chest pain or discomfort; note location, |Chest pain/discomfort is generally indicative of |Patient’s pulses remained strong and equal |

|cardiac workload by time of discharge. |radiation, severity, quality, duration, associated |inadequate blood supply to the heart, which can |bilaterally in all extremities. |

| |manifestations such as nausea, indigestion, and |compromise cardiac output. Clients with heart failure| |

| |diaphoresis. |can continue to have chest pain with angina or can | |

| | |reinfarct (Ackley, 2011). | |

|Patient will maintain strong, equal bilateral pulses |Closely monitor fluid intake, including intravenous |Maintain fluid restriction if ordered. In clients |The patient did walk around the room a little bit. |

|in radial and dorsalis pedis pulses until end of my |lines. |with decreased cardiac output, poorly functioning | |

|shift. | |ventricles may not tolerate increased fluid volumes | |

| | |(Ackley, 2011). | |

|The patient will display hemodynamic stability by |Refer patient to a heart failure program for |An assessment of a multidisciplinary heart failure | |

|time of discharge. |education, evaluation, and guided support to increase|center demonstrated that at six months, there were | |

| |activity and rebuild life. |significant improvements in quality of life and | |

| | |significant reductions in heart failure | |

| | |hospitalizations (Ackley, 2011). | |

| |Administer medications as ordered. |Many medications can increase the contractility of | |

| | |the heart and reduce the symptoms of heart failure | |

| | |(Ackley, 2011). | |

| |Encourage periods of rest and assist with all |Reduces cardiac workload and minimizes myocardial | |

| |activities. |oxygen consumption (Ackley, 2011). | |

| |Auscultate apical pulse, assess heart rate, rhythm. |Tachycardia is usually present to compensate for | |

| |Document dysrhythmia if telemetry is available. |decreased ventricular contractility. Other | |

| | |dysrhythmias are commonly associated with HF (Ackley,| |

| | |2011). | |

| |Palpate peripheral pulses. |Decreased cardiac output may be evident in diminished| |

| | |pulses (Ackley, 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 |

|* Dietary Consult |

|□PT/ OT |

|□Pastoral Care |

|□Durable Medical Needs |

|*F/U appointments |

|*Med Instruction/Prescription |

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

|□Rehab/ HH |

|□Palliative Care |

References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Chen, M. (2014, November 7). Pulmonary edema. Retrieved November 10, 2014, from



. (2014, January 1). Retrieved November 10, 2014, from

Diet and Congestive Heart Failure. (2014, January 1). Retrieved November 10, 2014, from



McLeod, S. A. (2008). Erik Erikson. Retrieved from

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