UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Dallas Hafner |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 3/31/2016 |

| ( 1 PATIENT INFORMATION |Agency: Morton Plant Mease |

|Patient Initials: HH |Age: 92 |Admission Date: 3/14/2016, wife drove to ED |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis: CHF (CHF exacerbation) |

|Primary Language: English | |

|Level of Education: Bachelors in Civil Engineering |Other Medical Diagnoses: (new on this admission) |

| |Acute Kidney Injury |

|Occupation (if retired, what from?): Civil Engineer | |

|Number/ages children/siblings: 1 boy child 62, 1 girl child 60 | |

|1 Brother 90, 1 Sister 93 | |

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|Served/Veteran: |Code Status: Full Code |

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

|Living Arrangements: Lives with wife at Royal Palms |Advanced Directives: Yes |

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

| |Surgery Date: NA Procedure: NA |

|Culture/ Ethnicity /Nationality: English American | |

|Religion: Protestant |Type of Insurance: Medicare |

|( 1 CHIEF COMPLAINT: “I was having trouble breathing and walking because of the excessive swelling in my legs” |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) Patient had a gradual increase in bilateral leg |

|swelling due to excessive fluid accumulation over the last couple weeks. The patient had increasing difficulty with walking, breathing and has gained excessive |

|weight. Patient’s baseline weight is 175lbs and upon arrival to the ED weighed in at 210 lbs. Patient is not experiencing any significant pain, but is |

|experiencing “discomfort”. The patient has not tried any other treatments besides his prescribed Lasix and heart medications. He confirms he has been consistent |

|with taking his medications. |

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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 |

|1980 |Left carotid endarterectomy |

|2008 |Coronary angiogram |

|2008 |Pacemaker placement |

|2011 |TURP |

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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 | | |

| |NKA | |

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

|etc.) | | |

| |NKA | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment): Heart failure is a chronic condition that results from a weakening heart. Patients typically |

|have cardiac dysfunction in their left or right ventricle or both. Left ventricular systolic dysfunction (left sided heart failure) often results in volume |

|overload and decreased contractility (Osborn et al., 2014). The LVSD is diagnosed by looking at the patient’s ejection fraction. Normal LVEF percentage is |

|between 55%-70% (Osborn et al., 2014). Right sided heart failure deals with the impaired ability of the right ventricle to pump blood (Osborn et al., 2014). As a|

|result, this can cause a backup of blood flow which is then followed by congestion and elevated pressure in the systemic veins and capillaries (Osborn et al., |

|2014). This condition of fluid congestion and overload is where the term congestive heart failure originates. A key point to remember is that right sided heart |

|failure is most commonly caused by left sided dysfunction. This patient is definitely experiencing insufficiencies in both ventricles. Risk factors for CHF |

|include hypertension (and all those risk factors for hypertension such as smoking, obesity etc.), CAD, MI, diabetes, and cardiomyopathies (Osborn et al., 2014). |

|There is not one diagnostic procedure or test to give a diagnosis of heart failure. Rather, CHF is diagnosed by looking at many diagnostic tests as well as blood |

|serum levels. Blood work tests that may give clues as to the etiology include CBC, ferritin, troponin, lipid panel and thyroid function tests (Osborn et al., |

|2014). Also, liver function tests, renal function tests and BNP testing may be used to determine the severity of the disease (Osborn et al., 2014). Diagnostic |

|testing includes chest X-rays, electrocardiograms and cardiac catheterizations. Treatments vary widely but typically include medications such as ACE inhibitors |

|and beta adrenergic blockers as a front line treatment. Other medications include dysrhythmic agents, inotropic agents, vasopressors and vasodilator agents |

|(Osborn et al., 2014). Pacemakers and ICDs may also be used in certain patients. Mortality from heart failure remains high as 290,000 people die annually and the|

|majority diagnosed with the condition die within 8 years (Osborn et al., 2014). Family history for various health conditions will increase your chances of |

|developing heart failure. These family or genetically linked health conditions would include CAD, diabetes, sudden cardiac death, valvular disease, conduction |

|system disease, collagen vascular disease, hypertension, hypercholesterolemia, cardiomyopathies, peripheral vascular disease, and skeletal myopathies (Osborn et |

|al., 2014). |

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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.] All medication information retrieved from (Unbound Medicine, 2014)

|Name: furosemide/Lasix |Concentration: 1 capsule |Dosage Amount: 40mg |

|Route: PO |Frequency: BID |

|Pharmaceutical class: Loop diuretic |Home Hospital or Both X (dose increased while in hospital) |

|Indication: Edema due to heart failure, hepatic impairment or renal disease, HTN |

|Adverse/ Side effects: SE – dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis |

|AE – erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, aplastic anemia, agranulocytosis |

|Nursing considerations/ Patient Teaching: change positions slowly to avoid orthostatic hypotension, educate about diet high in potassium, and advise doctor if |

|rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs. |

|Name: bumetanide (Bumex) |Concentration: 10mg/100 mL |Dosage Amount: 10 mg per day |

|Route: IV |Frequency: q20/HR, Rate 5mL HR |

|Pharmaceutical class: loop diuretic |Home Hospital X or Both |

|Indication: edema due to heart failure, hepatic disease, or renal impairment |

|Adverse/ Side effects: SE – hyperglycemia, dehydration, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis, hypotension. AE|

|– Stevens-Johnson syndrome, toxic epidermal necrolysis |

|Nursing considerations/ Patient Teaching: caution patient to change positions slowly, consult physician regarding diet high in potassium, advise doctor if patient |

|gains more than 3lbs per day, advise patient to contact provider if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs. |

|Name: acetylsalicylic acid, Aspirin |Concentration: 1 baby capsule |Dosage Amount: 81mg |

|Route: PO |Frequency: 1X daily |

|Pharmaceutical class: salicylates |Home Hospital or Both X |

|Indication: prophylaxis of transient ischemic attacks and MI |

|Adverse/ Side effects: SE – dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting. AE – GI bleeding, anaphylaxis, laryngeal |

|edema |

|Nursing considerations/ Patient Teaching: take with full glass of water and remain in upright position for 15-30 minutes after administration. Report tinnitus, |

|unusual gum bleeding, bruising, black tarry stools, do not use concurrently with alcohol, 3 or more glasses of alcohol a day may increase risk of GI bleeding, |

|caution when taking with other NSAIDS or acetaminophen. |

|Name: carvedilol/Coreg |Concentration: 1 capsule |Dosage Amount: 3.125 mg |

|Route: PO |Frequency: 1 tablet, BID |

|Pharmaceutical class: beta blocker |Home Hospital or Both X |

|Indication: hypertension, HF with digoxin, diuretics, and ACE inhibitors, left ventricular dysfunction after myocardial infarction |

|Adverse/ Side effects: SE dizziness, fatigue, weakness, diarrhea, erectile dysfunction, hyperglycemia. AE – bradycardia, HF, pulmonary edema, Stevens-Johnson |

|Syndrome, toxic epidermal necrolysis, anaphylaxis, angioedema. |

|Nursing considerations/ Patient Teaching: Take medication same time and every day, do not skip or double up on missed doses. Do not withdraw from medication |

|abruptly as this may cause life-threatening arrhythmias, hypertension or myocardial ischemia. Check pulse before taking medication and hold if pulse is less than |

|50 BPM. Avoid drinking alcohol and changing positions rapidly. Advise provider if slow pulse, difficulty in breathing, wheezing, cold hands and feet, dizziness, |

|confusion, depression, rash, fever, sore throat, unusual bleeding or bruising occurs. |

|Name: diltiazem/Cardizem |Concentration: 1 capsule |Dosage Amount: 120 mg |

|Route: PO |Frequency: 1 x daily |

|Pharmaceutical class: calcium channel blocker |Home Hospital or Both X |

|Indication: hypertension, angina pectoris, prinzmetal’s angina, supraventricular tachyarrhythmias, rapid ventricular rates in atrial flutter or fibrillation |

|Adverse/ Side effects: SE – peripheral edema, headache, nervousness, bradycardia. AE – Stevens-Johnson Syndrome, arrhythmias, heart failure |

|Nursing considerations/ Patient Teaching: monitor BP and pulse before therapy, monitor ECG, monitor intake and output ratios as well as daily weights, assess for |

|peripheral edema, rales/crackles, dyspnea, jugular vein distension. Watch for rash, fever muscle or joint aches, conjunctivitis and report these to provider |

|immediately. |

|Name: atorvastatin/Lipitor |Concentration: 1 capsule |Dosage Amount: 10mg |

|Route: PO |Frequency: 1 X daily |

|Pharmaceutical class: hmg coa reductase inhibitor |Home Hospital or Both X |

|Indication: management of hypocholesterolemia and mixed dyslipidemia |

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

|AE – rhabdomyolysis, antineurotic edema |

|Nursing considerations/ Patient Teaching |

|Name: oxycodone 5mg + acetaminophen 325mg/Percocet |Concentration: 1 Pill |Dosage Amount: oxycodone 5mg + acetaminophen 325mg |

|Route: PO |Frequency: PRN, 1 tablet Q6HR |

|Pharmaceutical class: Opioid agonists/non-opioid analgesics |Home Hospital X or Both |

|Indication: treatment of moderate to severe pain |

|Adverse/ Side effects: SE – confusion, sedation, constipation (oxycodone) |

|AE – respiratory depression (OC), hepatotoxicity in high doses (acetaminophen), Steven-Johnson Syndrome, toxic epidermal necrolysis |

|Nursing considerations/ Patient Teaching: advise patient that drug has high abuse potential, can cause drowsiness and dizziness, do not use concurrently with other|

|CNS depressants, advise patient to turn cough and deep breeze. |

|Name Potassium acetate |Concentration 20 mEq per pill |Dosage Amount 20 mEq |

|Route PO |Frequency BID |

|Pharmaceutical class mineral and electrolyte replacement |Home Hospital X or Both |

|Indication: treatment and prevention of electrolyte depletion |

|Adverse/ Side effects: SE – confusion, restlessness, weakness, ECG changes, irritation at IV site. AE – arrhythmias |

|Nursing considerations/ Patient Teaching: Educate patient regarding sources of dietary potassium. Patient to report dark, tarry stools, weakness, unusual fatigue,|

|tingling in the extremities, vomiting, diarrhea or stomach discomfort. Emphasize importance of regular follow up exams to monitor serum levels. |

|Name: warfarin/Coumadin |Concentration: 5mg per pill |Dosage Amount: 5 mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: anti-coagulant |Home Hospital or Both X |

|Indication: Prophylaxis treatment for atrial fibrillation with embolization |

|Adverse/ Side effects: SE – cramps, nausea, fever. AE - bleeding |

|Nursing considerations/ Patient Teaching: Do not double doses if dose is missed, review items high in vitamin K and ensure consistent limited intake of these |

|foods, avoid IM injections and to use a soft toothbrush, report any signs of black tarry stools, do not drink alcohol or start taking Aspirin without speaking with|

|doctor. Educate patient about importance of having regular lab tests drawn to maintain therapeutic range. |

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

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

|Diet patient follows at home? Salt restrictions |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: Cheese omelet or eggs for breakfast with fruit and cup |[pic] |

|of coffee (cream and sugar), Sandwich for lunch typically with a meat or multiple| |

|meats, Fruit snack during the day such as an apple or banana, steak for dinner | |

|with baked potato and glass of skim milk. | |

|Breakfast: Cheese omelet or eggs for breakfast with fruit and cup of coffee |The patient’s normal diet consists of approximately 1192 calories. Being a 92 |

|(cream and sugar) |year old main of healthy weight, this estimate could be accurate for his daily |

| |caloric intake.. There are a few areas of improvement I could recommend. |

| |Patient is very high in protein. I suggest he |

| |substitute his morning omelet for a bowl of steel cut oats. This would help him |

| |in the area of grains where he is falling short. I also suggest he add a fruit |

| |to his oatmeal. Additionally, he consumed 2344 mg of sodium on this day. |

|Lunch: Sandwich for lunch typically with a meat or multiple meats, Fruit snack |Being a cardiac patient, he should be consuming no more than 2,000 mg of sodium |

|during the day such as an apple or banana |daily to be considered low sodium. I think this highlights an important point |

| |for cardiac patients. It is very easy to hit your sodium intake |

| |without being excessive with salt. Salt is contained in many foods we are not |

| |even aware. By limiting his meat intake he can lower his sodium intake. Also, |

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|Dinner: Steak or another meat for dinner with baked potato and glass of skim |to look at nutrition labels carefully as a cardiac patient because foods you’d |

|milk. |never expect may be loaded with sodium. |

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|Snacks: tries to eat fruit as snacks | |

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|Liquids (include alcohol): Tea and coffee | |

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|[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’s wife is his best support and turns to her in time of need. |

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

|Patient will watch TV or run errands to get out of the house. Activities to take his mind off his condition are helpful and may also include cards with wife and |

|friends. |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): Patient states he is dealing with this fairly well |

|and understands he is getting older. He may get frustrated but doesn’t let it affect him to the point of becoming anxious or depressed. |

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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?  ___Na_________________ |

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|Are you currently in a safe relationship? Yes |

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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: |

|My patient was in the “Ego Integrity vs. Despair” stage of life. This stage is characterized by acceptance of one’s life, worth and eventual death (Treas and |

|Wilkinson, 2014). The stage will allow an individual to reflect on their satisfaction with life (Treas and Wilkinson, 2014). Patient seems to be happy with his |

|life and accepting of his current situation. The patient is proud of his children and what they’ve accomplished. He feels he has been a supportive and positive |

|role model in their life. The patient also spoke positively about his work life and career. He was very proud to talk about his positions as an engineer, and how|

|he accomplished roles very high up in his company. As discussed, the patient did not exhibit signs of depression or unhappiness. The patient realizes he has |

|lived a long and fulfilling life and is accepting of his deteriorating condition. These are all signs that the patient has achieved Ego Integrity rather than |

|Despair (Treas, L. S. and Wilkinson, J. M., 2014). |

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

|I believe the patient’s positivity towards life and his CHF condition has helped him to live a relatively healthy life towards this point. I think he will recover|

|from this acute exacerbation and return to living at home with his wife. He is not ready to quit on life and his positive attitude shows this. |

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|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” – “An aging and weakening heart and not going to the doctor soon enough” |

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|What does your illness mean to you? – Patient states his condition is just a normal part of aging. |

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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? ______No______________________________________ |

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

|vaccination? ____No____________________________________ |

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

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

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|How long have you been with your current partner?____60 years plus_________________________________________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity? No, but being older makes it more difficult___________________ |

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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?

_ attends church when able…a few times per month_____________________________________________________________________________

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Do your religious beliefs influence your current condition?

___________________________________________________NO_______________________________________________

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

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No x |

| If so, what? |How much?(specify daily amount) |For how many years? 50 years |

| |na |(age NA thru NA ) |

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

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

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

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

| What? Beer and liquor |How much? 2-3 drinks |For how many years? |

| |Volume: 2-3 liquor drinks or beer |(age 25 thru 50 ) |

| |Frequency: occasionally | |

| If applicable, when did the patient quit? 50 | | |

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

| If so, what? |

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

| |NA |(age NA thru NA ) |

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

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

|No |

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

|No |

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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: 50 | Diverticulitis | Life threatening allergic reaction |

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

|Other: na | Abdominal Abscess |Other: Patient does not have any immunologic |

| | |conditions |

|Be sure to answer the highlighted area | Last colonoscopy? NA | |

|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: na |

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

| 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 1x a year | | Intolerance to hot or cold |

|Other: | | Osteoporosis |

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|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? NA | Seizures |

| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? NA | menopause age? | Meningitis |

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

| |Date of DEXA Bone Density & Result: naNA NAfsNA | |

|Cardiovascular |Men Only |Mental Illness |

|Hypertension | Infection of male genitalia/prostate? na | Depression |

| Hyperlipidemia | Frequency of prostate exam? na | Schizophrenia |

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

|Myocardial Infarction | BPH | Bipolar |

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

|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? 3/4/16 |Arthritis | Chicken Pox |

|Other: |Other: |Other: |

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|General Constitution |

|Recent weight loss or gain |

|How many lbs? 35lbs from base weight |

|Time frame? 3 weeks |

|Intentional? No, fluid accumulation from CHF |

|How do you view your overall health? Good health |

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

|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 92 year old male of normal BMI. He has no visible signs of distress and is AO x 3. |

|Height: 5”10 |

|Weight: 190 lbs |

|BMI: 27.3 |

|Pain: 0/10 |

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|Pulse: 72 |

|Blood Pressure: (include location) 144/77 left arm |

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|Respirations: 18 |

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|Temperature: 97.5 femoral |

|SpO2 95 |

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

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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 |

|describe what was assessed in the physical exam that |

|was not WNL (within normal limits) |

| Central access device Type: NA Location: Date inserted: |

|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- 12 inches & left ear- 12 inches |

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

|Dentition: dentures |

|Comments: NA |

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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 x pale yellow yellow dark yellow green gray light tan brown red |

|Lung sounds: clear to the bases |

|RUL clear LUL clear |

|RML clear LLL clear |

|RLL clear |

| |

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

|Cardiovascular: No lifts, heaves, or thrills |

| |

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

| |

|Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze) Ventricular paced with occasional premature ventricular complexes |

| |

| |

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

| |

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

| |

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

| |

|Location of edema: lower legs bilaterally pitting x non-pitting |

| |

|Extremities warm with capillary refill less than 3 seconds |

| |

| |

| |

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

| |

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

| |

|Last BM: (date 1 / 18 /2016 ) Formed x Semi-formed Unformed Soft Hard x Liquid Watery |

| |

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

| |

|Nausea emesis Describe if present: None |

| |

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

| |

|Other – Describe: NA |

| |

| |

| |

|GU Urine output: Clear Cloudy Color: Previous 24 hour output: I – 1454 / O- 6850 mLs N/A |

| |

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

| |

|CVA punch without rebound tenderness |

| |

| |

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

| |

|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] |

| |

|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 NA |

| |

|NAStereognosis, graphesthesia, and proprioception intact NAGait 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: NA Biceps: NA Brachioradial: NA Patellar:NA Achilles:NA Ankle clonus: NA positive negative Babinski: NA 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): |

|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. |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|Na+: 138 |

|03/10/2016 |

| |

|Patient has remained in the normal range |

|Sodium levels are being monitored because of aggressive diuretic therapy and risk for hypo/hypernatremia |

| |

|K+: 3.7 |

|03/10/2016 |

|Patient has remained in the 3.5-4.0 range |

|Patient is on lower side of normal but within normal range. Value should be monitored closely to determine if potassium needs to be administered more aggressively. |

| |

|PT/INR: 31.2, 2.7 |

|03/10/2016 |

|Patient has remained in the therapeutic range of 2.0-3.0 INR. |

|Patient’s elevated PT/INR is as desired in the 2.0-3.0 range. |

| |

|EKG |

|03/10/2016 |

|NA |

|Ventricular-paced rhythm with occasional PVCs |

| |

|Echocardiogram |

|03/10/2016 |

|NA |

|RV with pacemaker placement, RV mildly dilated, mitral valve calcified, LV mildly dilated. Ejection fraction 45%-50%. |

| |

|All other lab values in normal range |

| |

| |

| |

| |

| |

|+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 – Up with assistance |

|Fall Risk Assessment – every shift (assess patient to monitor progressive and ensure safety measures are in place) |

|Braden Score – daily (immobility places patient at risk for developing a pressure ulcer |

|SCD – daily (immobility puts patient at greater risk for DVT |

|Strict I/O – daily (monitor for fluid retention or loss) |

|Vital Signs – Q8HR (monitor patient’s overall health status) |

|Weight 1 X daily (ensure patient isn’t retaining fluids or eliminating fluids too quickly) |

|Cardiac Diet (patient has history of CHF) |

|Consult to PT (PT to come and assist patient with ambulation for improvement and return to baseline) |

| |

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

| |

|1. Excess fluid volume r/t cardiac dysfunction as evidence by abnormal echocardiogram and ejection fraction of 45%-50% |

| |

| |

| |

|2. At risk for electrolyte imbalance r/t aggressive diuretic therapy |

| |

| |

| |

|3. At risk for dehydration r/t aggressive diuretic therapy |

| |

| |

| |

|4. |

| |

| |

| |

|5. |

| |

| |

| |

| |

| |

± 15 CARE PLAN

Nursing Diagnosis: See 3 Nursing Diagnosis Above, Resource used (Ackley and Ladwig, 2010) 

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

| | |Provide References | |

|Patient to maintain adequate blood pressure (Systolic|Assess patient’s blood pressure Q8 to ensure adequate|Maintaining adequate blood pressure during therapy |Met – on day of monitoring patient was able to |

|100-120, Diastolic 60-80) while on diuretic therapy |pressure and kidney perfusion. |ensures kidney perfusion and tissue perfusion |maintain blood pressure in normal range or slight |

|for entire stay at hospital. | |(Colucci, 2015) |above. |

|Patient to maintain clear lungs, elastic skin turgor,|Assess patient twice during shift paying special |Crackles in lungs can indicate fluid overload. Poor |Met – Patient assessment indicated no signs of |

|and moist mucous membranes while at hospital during |attention to areas of focus listed. |skin turgor and dry mucous membranes can indicate |dehydration. |

|diuretic treatment. | |patient is experiencing dehydration (Colucci, 2015) | |

|Maintain normal blood levels for the following kidney|Ensure morning blood draws are in normal range for |Maintaining normal kidney function during diuresis is|Met – patient’s values were in normal range. |

|function tests: creatinine (0.5-1.5 mg/dL) and BUN |creatinine and BUN |important to ensure adequate kidney function and to | |

|(7-20 mg/dL) | |avoid over diuresis (Colucci, 2015) | |

|Patient to maintain normal blood value levels for |Ensure morning blood draws are normal for potassium |Frequent monitoring of these electrolytes is |Met – patient maintained values in normal range. |

|potassium and magnesium while at hospital and |and magnesium. |important as hypokalemia and hypomagnesemia increase | |

|receiving diuretic therapy. | |risk for arrhythmias (Colucci, 2015) | |

|Patient to be on fluid restrictions of 1.5L – 2L per |Ensure intake is being monitored and recorded and |Hyponatremia is common among HF patients and degree |Met – Patient intake measured and also educated on |

|day while in hospital. |also educate patient on recommended daily intake |of reduction in serum sodium parallels the level of |1.5 L – 2 L intake allotment per day. |

| |volume. |severity of HF. Most patients with HF have | |

| | |hyponatremia as a result of volume overload (Colucci,| |

| | |2015) | |

|*Long Term Goal* Patient to maintain baseline weight |Educate patient on sodium restriction of less than 2 |Focus on these areas will help the patient to better |Ongoing – patient will be educated and strongly |

|of 175lbs when returning home from hospital |grams per day, importance of daily weight checks and |manage fluid balance and retention and as a result |encouraged to follow these guidelines. |

| |importance of maintaining strict adherence to |improve his decompensated heart condition (Colucci, | |

| |diuretic medication plan. Patient needs to report to|2015) | |

| |doctor a gain of more than 5lbs per week. | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|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 |

|* 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. and Ladwig, G. B. (2010).  Nursing diagnosis handbook: An evidence-based guide to planning care. Edited by Gail Ackley. 9th ed. Maryland Heights, MO: Elsevier Health Sciences.

Colucci, W.S., (2015). Treatment of acute decompensated heart failure: Components of therapy. Uptodate. Retrieved from



Colucci, W.S., (2015). Patient information: heart failure (beyond the basics). UpToDate. Retrieved from



Osborne, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing preparation for practice (2nded.). Upper Saddle River, NJ: Pearson.

SuperTracker: My Foods. My Fitness. My Health. Received from: (Accessed: 9 April 2016).

Treas, L. S. and Wilkinson, J. M. (2014). Basic nursing: Concepts, skills & reasoning. Philadelphia, PA: F.A. Davis Company.

Unbound Medicine, Inc. (2014). Nursing Central (1.22.) [Mobile application software]. Retrieved from < > 

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