UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Shawn Hekkanen |

|Patient Assessment Tool . |Assignment Date: 10/1/2015 |

| ( 1 PATIENT INFORMATION |Agency: TGH - SBN |

|Patient Initials: AAA |Age: 74 years old |Admission Date: xx/xx/2015 |

|Gender: Male |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: Nonrheumatic Mitral Valve |

| | |Insufficiency/ I34.0 |

|Primary Language: English | |

|Level of Education: 2 Master’s Degrees- History, English |Other Medical Diagnoses: (new on this admission): atrial |

| |fibrillation(I48.91), sleep apnea(G47.30, Pulmonary HTN(I27.0), |

| |chronic bronchial cough(R05), extended spectrum beta lactamase(Z16.12)|

|Occupation (if retired, what from?): Retired – Agent Federal Bureau of Investigation | |

|Number/ages children/siblings: 1 son (38 years old), 1 daughter (42 years old) | |

| | |

|Served/Veteran: Veteran – Army – 2 tours Vietnam, honorable discharge |Code Status: Full Code |

|Living Arrangements: lives with wife and rents properties in Virginia, Florida, the country|Advanced Directives: Completed |

|of Vietnam throughout the year |If no, do they want to fill them out? |

| |Surgery Date: 9/22/2015 |

| |Procedure: mitral valve repair, coronary artery bypass graft harvested|

| |from left saphenous vein |

|Culture/ Ethnicity /Nationality: Caucasian, born United States, ancestors are from Britain | |

|Religion: No affiliation |Type of Insurance.: (retired) Federal Employee Plan, Medicare |

|( 1 CHIEF COMPLAINT: |

|Patient checked into Tampa General Hospital after drastic increases in episodes of dyspnea, fatigue, and severe headaches. Patient reports he was unable to catch |

|his breath after grocery shopping. He has a history of care under a cardiologist in Virginia for mitral valve insufficiency, pulmonary hypertension, and atrial |

|fibrillation. “I could not catch my breath. It hurt and I panicked. It was scary. I ate right, exercised, and did a lot right. I could not catch my breath and I |

|usually can after resting a bit. My mitral valve was not supposed to go out so soon. I saw my cardiologist in Virginia just before coming to Florida. Patient |

|reported that this pain was a “10” and it was “pressure.” |

| |

| |

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

|Patient reports that he has been on a planned vacation in Florida from Virginia. He had been diagnosed with minor mitral valve insufficiency “many, many years” |

|prior, under the care of a cardiologist in Virginia. Patient’s other formal diagnoses prior to this hospitalization include malignant hypertensive heart disease |

|without congestive heart failure, paroxysmal atrial fibrillation, and pulmonary hypertension arterial disease. In June 2015, an echocardiogram had results of pulse|

|pressure 60mmHg and pulmonary hypertension. Ejection fraction was “within normal range.” Patient’s Virginia cardiologist had approved the patient for travel to |

|Florida in August, under their agreed upon treatment plan, whereby the patient would not have surgery until severe failure of the mitral valve. The onset of severe|

|dyspnea lead to hospitalization. Patient had intended to stay in Florida for two months before returning to Virginia. He is currently having pain from the surgical|

|incision that is over the length of the sternum. He reports a pain level of “7,” and is aching, intermittent, and has gradual onset. Relief occurs by PRN |

|medication hydrocodone-acetaminophen. Movement may make the pain worse. Patient reported thinking that he may have been able to successfully delay surgery until, |

|“I would be old enough not to go through with it.” Patient did not want to immediately have the heart surgery at TGH, hoping to “return to Virginia.” He consented |

|to two other procedures, a colonoscopy and esophagogastroduodenoscopy with closed biopsy, due to constant heartburn, tarry stool, and having the feeling that food |

|was stuck behind his sternum. Since the patient had adapted a disciplined lifestyle to have a heart healthy diet and daily light exercise, he reports that he was |

|hoping to medicate through the mitral valve regurgitation crisis without surgery. Patient now has been diagnosed with an extended spectrum beta lactamase infection|

|and has contact precautions. Breathing treatments are daily for lung congestion and productive cough. He is not on an oral antibiotic. The plan is to eventually |

|discharge to a Florida rehab facility. The patient reports weakness in legs and arms. He becomes easily tired and easily dizzy. During the evaluation he thought |

|his son was 28 years old instead of 38 years old. However, all other recall appeared to be accurate and immediate. Patient’s wife appears to be integral to any |

|treatment plan for both support and correct application. |

| |

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

|Date |Operation or Illness |

|1998 |Left inguinal hernia repair |

|2001 |Right inguinal hernia repair |

|2008 |Lithotripsy for kidney stone |

|8/31/2015 |colonoscopy |

|8/31/2015 |Esophagogastroduodenoscopy with closed biopsy |

|9/22/2015 |Coronary artery bypass graft (CABG) with harvest from Left saphenous vein, repair of mitral valve |

|9/24/2015 |Noted infection of Extended Spectrum Beta Lactamase (ESBL) –contact precautions |

| | |

|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Sister has no known health issues. Children have no known health issues. Grandchildren have no known health issues. |

| |“Nobody in my family has mental health issues or substance abuse issues. Never.” |

| | |

| | |

| | |

| | |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations: (Note- patient is 78 years old) | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) | | |

|Adult Tetanus (Date) | | |

|Influenza (flu) (Date) 11/2014 (intention to get flue shot this year | | |

|Pneumococcal (pneumonia) (Date): unknown | | |

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

|encephalitis, typhoid, Hep A & B | | |

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

|REACTIONS |Causative Agent | |

|Medications |No known Drug Allergies or |No known drug allergies |

| |adverse drug reactions | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, |Some environmental grasses |Rhinitis, itchy eyes – treated with OTC Benadryl |

|etc.) |especially in Virginia | |

| |(unknown specific grass, | |

| |occurs in spring and fall) | |

| | | |

| | | |

| | | |

|( 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) |

|The most common cause of mitral valve insufficiency is leaflets of the valve are remodeled due to increased proteinases and myofibroblast infiltration (Huether & |

|McCance, 2012). Blood leaks back into the atrium during ventricular contraction. Prevalence of disorder is 2.4% of the United States adult population, and there is|

|a link to being a dominant allele of inheritance. During the fifth to sixth week of gestation, the mitral valve formation can be disrupted by environmental |

|factors. Often, mitral valve insufficiency does not have any overt symptoms. The murmur is discovered during routine examination by auscultation. Discovery may |

|also be confirmed by echocardiography. If symptomatic, patients can experience dysrhythmias, tachycardia, dizziness, syncope, fatigue, lethargy, weakness, dyspnea,|

|chest tightness, hyperventilation, anxiety, depression, and atypical chest pain. Left sided heart failure can cause pulmonary hypertension (Huether & McCance, |

|2012). Severity and emergence of specific symptoms are difficult to match to the level of prolapse. Most patients do not have restricted activities or medications.|

|However, beta-blockers may be prescribed, especially for dizziness and palpitations. Clinical findings and echocardiograph may indicate that a person with mitral |

|valve insufficiency would also be at risk for endocarditis, stroke, and sudden death. A bioprothetic or mechanical heart valve may replace the faulty mitral |

|valve. Bioprosthetics are from a cow or a pig, and usually last about 10-20 years (Osborn, Wraa, Watson, & Holleran, 2014). Long-term anticoagulant prescriptions |

|are not as common. Clot risks are higher for mechanical valve replacement and lodge right on the valve. The patient’s blood levels for coagulants have to be |

|carefully monitored, and anticoagulant therapy will be prescribed. |

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

|Name docusate sodium(COLACE) |Concentration |Dosage Amount 100mg |

|Route by mouth |Frequency BID (twice daily) |

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

|Indication Constipation prevention to avoid straining, especially after MI, heart surgery, or rectal surgery |

|Side effects/Nursing considerations: throat irritation, abdominal cramps, diarrhea, and rashes. Assess for abdominal distention, auscultate bowel sounds, and |

|record bowel patterns of elimination. Assess color, odor, consistency, and amount of stool |

| |

|Name guaifenesin (MUCINEX) |Concentration |Dosage Amount 600mg |

|Route by mouth |Frequency BID every 12hr PRN for congestion and cough |

|Pharmaceutical class: expectorant; allergy/cold/cough |Home Hospital or Both |

|Indication: For productive cough related to upper respiratory infection. Reduces viscosity of bronchial secretions by increasing amount of fluid in respiratory |

|tract. |

|Side effects/Nursing considerations: dizziness, headache, nausea, diarrhea, rash, hives, vomiting, light-headedness. Assess lung sounds and frequency/character |

|of cough and bronchial secretions. Maintain 1500-2000mL water intake to potentiate effect on secretion viscosity and limit light-headedness. |

| |

|Name heparin (porcine) |Concentration |Dosage Amount 5000units |

|Route subcutaneous injection abdomen |Frequency BID |

|Pharmaceutical class: antithrombotics |Home Hospital or Both |

|Indication: Prophylaxis or treatment of thromboembolism related disorders throughout circulatory system. Anticoagulant. |

|Side effects/Nursing considerations: Bleeding, thrombocytopenia, anemia, alopecia with long-term use, and osteoporosis with long-term use. Assess for signs of |

|bleeding and hemorrhage, such as nosebleeds, bruising, tarry stools, fall in hematocrit or fall in BP. Observe injection sites for hematoma, bruising, and |

|inflammation. Monitor platelet count. |

| |

|Name hydrochlorothiazide (HYDRODIURIL) |Concentration |Dosage Amount: 25mg |

|Route by mouth |Frequency daily |

|Pharmaceutical class: thiazide diuretics |Home Hospital or Both |

|Indication: Management of mild to moderate hypertension. Treatment associated with heart failure, renal dysfunction, cirrhosis, and glucocorticoid therapy. |

|Side effects/Nursing considerations : hypotension, cramping, Stevens Johnson syndrome, rash, hyperglycemia, hypokalemia, hyperuricemia, and hypovolemia. |

|Monitor BP, heart rate, intake/output, daily weight, and edema especially in lower extremities, low sodium, low magnesium, and high calcium. Monitor dizziness and |

|orthostatic hypertension. Fall risk. |

| |

|Name HYDROcodone-acetaminophen (NORCO) |Concentration |Dosage Amount: 5-235mg per tablet |

|Route |Frequency PRN every 6 hours |

|Pharmaceutical class: opioid agonist w/ non-opioid analgesic |Home Hospital or Both |

|combination | |

|Indication: Management of Mild Pain(1-3) to Moderate Pain(4-6) that is daily, around-the-clock, and long-term. |

|Side effects/Nursing considerations: Do not exceed 4g of acetaminophen combined from all sources within 24 hours. Confusion, dizziness, sedation, euphoria, |

|urinary retention, constipation, respiratory depression, vision changes, headache, unusual dreams. |

| |

|Name insulin aspart (NOVOLOG) |Concentration |Dosage Amount sliding scale |

|Route subcutaneous injection |Frequency: Three times daily with food and at bedtime |

|Pharmaceutical class: pancreatics |Home Hospital or Both |

|Indication: Blood sugar ................
................

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

Google Online Preview   Download