UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Chelsea Burns |

|MSI & MSII Patient Assessment Tool . |Assignment Date: 01-26-2016 |

| ( 1 PATIENT INFORMATION |Agency: SJH |

|Patient Initials: W. B |Age: 49 |Admission Date: 01-19-2016 |

|Gender: M |Marital Status: Single |Primary Medical Diagnosis: HTN, DM Type 2, |

|Primary Language: English |dyslipidemia, obesity (morbid), neuropathy |

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

|Occupation (if retired, what from?): Business Owner, Vendor with Hillsborough County Schools|Pulmonary embolism ICD-10 126.99, |

| |CHF ICD-10 150.9 |

|Number/ages children/siblings: | |

|Children: 28 y/o daughter, one 11 y/o son | |

|Siblings: three sisters ages 54, 53, 51; one brother 37 y/o | |

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

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

|Living Arrangements: Home owner and lives with his son and daughter |Advanced Directives: Yes |

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

| |Surgery Date: N/A Procedure: N/A |

|Culture/ Ethnicity /Nationality: African American | |

|Religion: Baptist/Christian |Type of Insurance: Temporary insurance while in hospital. |

|( 1 CHIEF COMPLAINT: |

|“Feet were numbness and tingling, I think they call it neuropathy and I had a lot of chest pains… some discomfort in my chest…it was more intuition than anything |

|else.” |

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

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|The patient is a 49-year-old male that came to the emergency room with complaints of chest pain that he first noticed 2 months ago, but became increasingly painful|

|in the past 1 to 2 weeks. His pain is located primarily in the chest, it does not radiate, and lasts about 20 minutes long. The patient described the pain as, |

|“sharp, shooting, and changing intensity.” When the patient exerts himself, or sits upright, the pain worsens, however; when he is reclined in a chair or lying |

|supine, he feels some relief. The patient did not try any treatments or over the counter medications to relieve his chest pain, except massaging the area. He rated|

|his pain as a 5 on a scale from 0-10. While in the emergency room, the patient had a chest x-ray that was negative. Following the x-ray, a CT scan showed signs of |

|pulmonary embolism. He was placed on EKG and readings showed left ventricular hypertrophy but no ST elevation or depression. The patient was then moved to the |

|telemetry floor and started on anticoagulation, oxygenation PRN, pain management, antihypertensive, and an insulin regimen. |

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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 |

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|05/2014 |Hospitalized for pneumonia, treated with penicillin abx, discovered Type II diabetes, diagnosed with HTN, obesity, dyslipidemia, was |

| |sent home on oral antidiabetics metformin 500mg/day and glipizide 10mg BID, Lisinopril 40 mg 1x daily, hydrocholorthiazide 25mg 1x |

| |daily, and pravastatin 20mg 1xdaily |

|03/2015 |Hospitalized for nausea, abdominal pain, dizziness, syncope for hyperglycemia due to incompliance with diabetic regimen, was stabilized |

| |with insulin, educated about diet, and sent home on oral antidiabetic metformin 500mg/day and glipizide 10mg BID. |

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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 |No Allergies | |

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|Other (food, tape, latex, dye, |No Allergies | |

|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) |

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|Mechanics of the disease: The patient was admitted for chest pain and is now being treated for a pulmonary embolism (PE). A pulmonary embolism is an occlusion of |

|part of pulmonary artery that blocks blood flow to the area distal to the occlusion (Osborn, Wraa, Watson, & Holleran, 2014). The embolus that causes the |

|occlusion, originates from somewhere else in the body and then travels to the pulmonary artery where it lodges (Osborn et al., 2014). Approximately 90% of the |

|blockages come from a thrombus that has originated in the deep veins of the lower extremities (Osborn et al., 2014). The occlusion causes complications such as |

|impaired ventilation, perfusion, hypoxemia and possibly atelectasis (Osborn et al., 2014). |

|Risk Factors: The risk factors for pulmonary embolism include immobilization, surgery in the past 3 months, pregnancy, stroke, paralysis, chronic heart disease, |

|and history of venous thromboembolism (Osborn et al., 2014). Immobility is the greatest risk factor contributing to pulmonary embolism because during sedentary |

|times, the blood flow slows increasing risk for clots that can then mobilize with movement (Osborn et al., 2014). Risk factors that increase likeliness of a DVT |

|(deep vein thrombosis) such as hypercoagulation disorder, trauma to the lower extremity, estrogen therapy, thrombophilia, and congestive heart failure also |

|increase risk for a pulmonary embolism because of the high correlation between DVT and PE (Osborn et al., 2014). |

|How to Diagnose: The most accurate way to detect a pulmonary embolism is by performing a pulmonary angiography (Osborn et al., 2014). This test gives a 100% |

|accuracy in showing that the pulmonary artery has been obstructed and blood flow has been compromised (Osborn et al., 2014). However, most patients with chest |

|pain, will have an x-ray first and that test does not show perfusion patterns so it is important to follow up with other testing (Osborn et al., 2014). Alternative|

|tests that can contribute to the diagnosis of pulmonary embolism, include: CT angiography, ultrasound of lower extremity to detect DVT, and V/Q scan (Osborn et |

|al., 2014). The V/Q scan shows ventilation and perfusion of the lung and may not always be accurate therefore it should be used in addition to other tests. ABGs, |

|pulse oximetry, WBC count, EKG, and the D-dimer test may also help to confirm diagnosis (Osborn et al., 2014). |

|Treatment: There are several different methods of treatment for a pulmonary embolism. The primary treatment is anticoagulation, typically with low molecular weight|

|heparin subcutaneous injection as the preference and then oral warfarin to continue treatment for 3 to 6 months (Osborn et al., 2014). Another form of treatment is|

|fibrinolysis, this uses medications such as streptokinase, urokinase, or t-PA to decrease the clot size by thrombolysis (Osborn et al., 2014). For patients that |

|can not tolerate anticoagulants or fibrinolysis, an Inferior Vena Cava Filter is placed through the jugular or femoral vein to allow blood flow and prevent emboli |

|from blocking the lungs (Osborn et al., 2014). The final treatment for pulmonary embolism is an embolectomy, where a catheter is guided up into the pulmonary |

|artery to break up the clot (Osborn et al., 2014). |

|Prognosis: Approximately 10% of the 600,000 patients diagnosed annually die from complications and 30% of those untreated will die (Osborn et al., 2014). Patients |

|that do survive a pulmonary embolism have increased risk of reoccurrence, pulmonary hypertension or cor pulmonale (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.]

|Name: aspirin |Concentration |Dosage Amount: 1 81mg tab |

|Route: PO |Frequency: 1x daily with meals |

|Pharmaceutical class: Salicylate- antipyretic, non-opioid analgesic |Home Hospital or Both; patient new to med and will start taking at home |

|Indication: Patient is to take 1 aspirin a day to decrease platelet aggregation to decrease incident of ischemic attacks, MI, and another PE. |

|Adverse/ Side effects: GI bleeding, allergy, anaphylaxis, laryngeal edema, dyspepsia, epigastric distress, n/v |

|Nursing considerations/ Patient Teaching: Nursing considerations: assess for fever, monitor hepatic function for elevated AST, ALT and alkaline phosphatase, |

|monitor for prolonged bleeding and monitor for toxicity/overdose: tinnitus, HA, hyperventilation, mental changes, sweating. Patient teaching: Take 1 81mg tab daily|

|with meals. If you notice any bleeding of the gums, bruising, black tarry stools, or fever report to provider. Also, do not drunk alcohol to prevent GI irritation |

|and bleeding. Do not take with NSAIDS unless given permission. |

|Name: gabapentin (Gralise, Horizant, Neurontin) |Concentration |Dosage Amount: 300mg |

|Route: PO |Frequency: 2x daily |

|Pharmaceutical class: analgesic adjuncts, anticonvulsant, mood |Home Hospital or Both; patient new to med and will start taking at home |

|stabilizer | |

|Indication: diabetic peripheral neuropathy pain |

|Adverse/ Side effects: suicidal thoughts, rhabdomylosis, multiorgan hypersensitivity reactions, confusion, depression, dizzy, drowsy, ataxia |

|Nursing considerations/ Patient Teaching: Nursing consideration: monitor for changes in behavior, assess location of pain and improvement after medication. Patient|

|teaching: Notify provider if feeling thoughts of suicide or depression, or any changes in behavior. Do not take within 2 hr. of antacid, take it exactly as |

|prescribed and don’t wait more than12 hours between doses. |

|Name: hydrochlorothiazide (Microzide, Oretic, Urozide) |Concentration |Dosage Amount: 25 mg |

|Route: PO |Frequency: 1 tab, 1x daily |

|Pharmaceutical class: antihypertensive diuretic/ thiazide diuretic |Home Hospital or Both |

|Indication: manage hypertension and edema with HF |

|Adverse/ Side effects: stevens Johnson syndrome, hypokalemia, dehydration, dizzy, drowsy, n/v, hyponatremia, hypovolemia, electrolyte imbalances |

|Nursing considerations/ Patient Teaching: Nursing considerations: monitor BP, I&O, daily weight, and edema daily, assess for hypokalemia, and allergy to |

|sulfonamides. Monitor electrolytes, blood glucose, Bun/Cr, and uric acids. Patient teaching: monitor weight biweekly and notify if changes, stand up slowly for |

|orthostatic hypotension, comply with weight reduction, low-sodium diet, regular exercise, monitor BP, take in the morning to avoid nocturia |

|Name: Lisinopril (Prinivil, Zestril) |Concentration |Dosage Amount: 40mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: ACE inhibitor |Home Hospital or Both |

|Indication: To manage hypertension and heart failure |

|Adverse/ Side effects: angioedema, cough, dizziness, hypotension, hyperkalemia, impaired renal function, headache |

|Nursing considerations/ Patient Teaching: Nursing considerations: monitor BP and pulse, asses for angioedema, monitor weight and fluid overload S&S. Watch renal |

|function labs, hyperkalemia, CBC, and liver function labs. Patient teaching: take as directed, monitor BP daily, avoid salt substituted with potassium, or foods |

|high in potassium, change positions slowly, notify provider with persistent dry cough, rash, mouth sores, irregular hand or feet, or difficulty swallowing, |

|Name: pravastatin (Pravachol) |Concentration |Dosage Amount: 20 mg |

|Route: PO |Frequency: 1x daily |

|Pharmaceutical class: HMG CoA reductase inhibitor; lipid-lowering agent |Home Hospital or Both |

|Indication: management of dyslipidemias and hypercholesterolemia, prevent coronary heart disease |

|Adverse/ Side effects: rhabdomylosis, abdominal cramps, constipation, rash, diarrhea, flatus, heartburn, hyperglycemia |

|Nursing considerations/ Patient Teaching: Nursing considerations: review diet history, evaluate cholesterol and triglyceride levels, monitor liver function and CPK|

|levels. Patient teaching: Avoid grapefruit juice, adhere to diet restricting fats, cholesterol, carbohydrates, and alcohol. Try to participate in exercise. Notify |

|provider with muscle pain, tenderness, weakness, fever, or malaise. Take at bedtime because that’s when your cholesterols are being made. |

|Name: warfarin (Coumadin) |Concentration |Dosage Amount: 7.5 mg |

|Route: PO |Frequency: 1xdaily |

|Pharmaceutical class: anticoagulant |Home Hospital or Both patient will be d/c with new medication |

|Indication: prophylaxis of venous thrombus formation, pulmonary embolization, and atrial fibrillation with PE |

|Adverse/ Side effects: bleeding, cramps, nausea, dermal necrosis, fever |

|Nursing considerations/ Patient Teaching: Nursing considerations: watch for bleeding and hemorrhage, monitor PT/INR for therapeutic levels (2.5-3.5 for this |

|patient is therapeutic) monitor hepatic function and CBC as well. Prepare vitamin K as antidote if necessary. Patient teaching: do not ingest large quantities of |

|vitamin K, maintain regular diet of vitamin K, if you are changing your diet consult with physician first. Take as prescribed and notify if any irregular bleeding |

|occurs, gums, bruising, nosebleed, hematuria, etc. Avoid activities that increase risk of bleeding. Use a soft toothbrush, do not floss, use an electric razor, and|

|apply pressure to prevent bleeding if it does occur. Have frequent lab tests to monitor PT and coagulation. Notify a provider you’re taking warfarin before any |

|surgery and stop taking 3-7 days prior. |

|Name: heparin drip (Hepalean, Hep-Lock) |Concentration: 25,000 units in 250 mL of dextrose 5% |Dosage Amount: 1,900 units/hr |

| |= 50units/mL |titration, weight based, start at 15 units/kg/hr |

| | |(max of 2000 units/hr). Give at least 5 days until |

| | |INR is greater than or equal to 2 for 24 hours. |

|Route: IV |Frequency: continuous titration |

|Pharmaceutical class: antithrombotics |Home Hospital or Both |

|Indication: prophylaxis and treatment of venous thromboembolism, pulmonary emboli, afib, coagulopathies, peripheral arterial thromboembolism |

|Adverse/ Side effects: bleeding, heparin induced thrombocytopenia, anemia, hepatitis, rash, fever |

|Nursing considerations/ Patient Teaching: Nursing considerations: assess for bleeding and hemorrhage, monitor for hypersensitivity, timely lab draws before dose |

|adjustment, monitor aPTT, INR per MD orders, platelet count, liver function levels, and hyperkalemia. Prepare protamine sulfate as antidote if needed. Patient |

|teaching: report any signs of bleeding, do not take NSAIDS, avoid activities that increase risk of bleeding. Use a soft toothbrush, do not floss, use an electric |

|razor, and apply pressure to prevent bleeding if it does occur |

|Name: heparin bolus (Hepalean, Hep-Lock) |Concentration: |Dosage Amount: 0.5 mL= 2,500 units |

|Route: IV injection |Frequency: bolus dose for use during titration of heparin drip, if aPTT less than|

| |or equal to 40 seconds, and drip has already been started. |

|Pharmaceutical class: antithrombotic |Home Hospital or Both |

|Indication: prophylaxis and treatment of venous thromboembolism, pulmonary emboli, afib, coagulopathies, peripheral arterial thromboembolism |

|Adverse/ Side effects: pain at injection site, bleeding, heparin induced thrombocytopenia, anemia, hepatitis, rash, fever |

|Nursing considerations/ Patient Teaching: Nursing considerations: assess for bleeding and hemorrhage, monitor for hypersensitivity, timely lab draws before dose |

|adjustment, monitor aPTT, INR per MD orders, platelet count, liver function levels, and hyperkalemia. Prepare protamine sulfate as antidote if needed. Patient |

|teaching: report any signs of bleeding, do not take NSAIDS, avoid activities that increase risk of bleeding. Use a soft toothbrush, do not floss, use an electric |

|razor, and apply pressure to prevent bleeding if it does occur |

|Name: insulin Determir (Levermir) |Concentration |Dosage Amount: 60 units = .6mL |

|Route: subcutaneous inj. |Frequency: 2x daily |

|Pharmaceutical class: antidiabetics |Home Hospital or Both |

|Indication: long-acting control of hyperglycemia in DM |

|Adverse/ Side effects: hypoglycemia, lipodystrophy, allergy |

|Nursing considerations/ Patient Teaching: Nursing considerations: give in morning and at night either with meals or 12 hours after morning dose, watch for signs of|

|hypoglycemia such as anxiety, restlessness, tingling in hands, cool, pale skin, hunger, irritability, tachycardia, tremors. Monitor body weight and changes. |

|Monitor blood glucose every 6 hours and can check hemoglobin A1C every 3-6 months. Do not mix with any other insulin and rotate injection sites. Patient teaching: |

|instruct proper administration, discuss insulin syringes and checking blood glucose. Teach the recognition of hyper and hypoglycemia and to carry a source of sugar|

|with them at all times. |

|Name: insulin Aspart (novolog) |Concentration |Dosage Amount: 10 units= 0.1 mL |

| | |Frequency: 3x daily, before each meal |

| | |Dosage Amount: BG sliding scale |

| | |Frequency: 1xdaily at bedtime |

| | |Dosage Amount: BG sliding scale |

| | |Frequency: 3x daily, before each meal for |

| | |additional coverage to the 10 units |

|Route: subcutaneous inj. |Frequency: (listed above) |

|Pharmaceutical class: antidiabetics |Home Hospital or Both |

|Indication: short-acting control of hyperglycemia in DM |

|Adverse/ Side effects: hypoglycemia, lipodystrophy, allergy |

|Nursing considerations/ Patient Teaching: Nursing considerations: give before meals after checking blood glucose. Onset is within 15 minutes so have meals ready to|

|give. Watch for signs of hypoglycemia such as anxiety, restlessness, tingling in hands, cool, pale skin, hunger, irritability, tachycardia, tremors. Monitor body |

|weight and changes. Can check hemoglobin A1C every 3-6 months. Rotate injection sites. Patient teaching: instruct proper administration, discuss insulin syringes |

|and checking blood glucose. Teach the recognition of hyper and hypoglycemia and to carry a source of sugar with them at all times. |

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

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|Diet ordered in hospital? | |

|Patient was on cardiac, low sodium diet in the hospital. | |

|Diet patient follows at home? | |

|Patient states that he does not follow a specific diet at home but that he tries his best to avoid unhealthy foods. | |

|24 HR average home diet: | |

|Breakfast: Patient states that he eats 3 scrambled eggs and 4 pieces of bacon regularly. He also has about an 8oz glass of fruit juice. | |

|Lunch: Patient states that he usually eats a large sandwich that has 4 slices of flavored turkey, a couple pieces of lettuce, a couple slices of tomato, | |

|mayonnaise, and honey mustard with a side salad. He said that he uses ranch dressing, and has carrots, cheese, and croutons on his salad. He also states | |

|that he eats it with a small bag of potato chips or Cheetos and drinks about 1 bottle of water. | |

|Dinner: Patient states that for dinner he usually eats a full portion of turkey, fish, or fried chicken with about a cup of vegetables and about a half a | |

|place of rice. Most often the vegetable is corn or broccoli. | |

|Snacks: Patient states that his snacks consist of fruit, junk food such as chips and cookies, and kid snacks such as crackers and fruit chews. Patient | |

|states that he will have about 3 snacks a day. | |

|Liquids: Patient states that he typically drinks 8 oz. cran-grape juice, 8 oz. grapefruit juice, 16 oz. water and 16 oz. of sweet tea. | |

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|24 HR Diet Recall: | |

|Breakfast: Patient states that for breakfast he ate about a quart of a plate of scrambled eggs, a piece of French toast, and a chicken sausage patty. | |

|Lunch: Patient states that he ate a turkey sandwich with lettuce, tomatoes, mayonnaise, onion, and had 8 oz. of water. | |

|Dinner: Patient states that his previous dinner was half of a baked chicken, green beans, and 4 oz. of water and 8 oz. of apple juice. | |

|Breakfast: Patient states that for breakfast he ate eggs, toast with butter, and 8 oz. of orange juice | |

|[pic] |

|Added Sugars |

|Eaten: 76 g Limit: 50 g |

|Saturated Fat |

|Eaten: 35g Limit: 22g |

|Sodium |

|Eaten: 4906mg Limit: 2300mg |

|Total Calories Eaten: 2965 [pic] |

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|Analysis: |

|According to the MyPlate food tracker, this patient is consuming adequate protein and refined grains, however; he is not consuming enough fruits and |

|vegetables (United States Department of Agriculture, 2013). Although, this patient needs to shift his diet to consume healthier foods, like fruits and |

|vegetables, the main concern with this patient, is that he is consuming too much of added sugars, saturated fats, and sodium (United States Department of |

|Agriculture, 2013). All of these foods, contribute to his disease processes. The added sugars are contraindicated because of his type 2 diabetes. Consuming|

|too much of theses additional sugars, especially for a non-compliant diabetic, will cause further hyperglycemia as well as worsening microvascular |

|complications (Osborn et al., 2014). In type 2 diabetes, the body is unable to maintain an effective insulin level to compensate for all the additional |

|sugar, and therefore his; blood sugar will become dangerously high (Osborn et al., 2014). I would recommend the patient avoiding sweet tea, artificially |

|sweetened fruit juice, fruit snacks, and cookies (United States Department of Agriculture, 2013). The saturated fats are also over consumed and should be |

|limited due to his recent pulmonary embolism and new diagnosis of congestive heart failure (United States Department of Agriculture, 2013). Saturated fats |

|contribute to his dyslipidemia and cause atherosclerosis of the vasculature (Osborn et al., 2014). This increases the likelihood for plaque build up and |

|the reoccurrence for a thrombotic event (Osborn et al., 2014). Overall, saturated fats compromise the health of the vasculature and may lead to additional |

|ischemic events (Osborn et al., 2014). I would recommend that this patient decrease his consumption of butter, mayonnaise, honey mustard, and fried foods |

|(United States Department of Agriculture, 2013). In addition to sugar and saturated fats being hazardous to his health, the elevated sodium intake presents|

|another major risk. Sodium causes water retention, and any increase in fluids causes an increase in blood pressure, consequently the heart is put under |

|more stress and will continue to remodel and decrease cardiac output (Osborn et al., 2014). Congestive heart failure patients already have issues with high|

|pressures, fluid overload, and edema, therefore; eliminating or restricting sodium, to about 1.5-2 grams a day, is essential to prevent hypertension and |

|worsening heart failure (Osborn et al., 2014). I would recommend that this patient avoid salty food such as bacon, chips, salted vegetables and rice |

|(United States Department of Agriculture, 2013). Finally, this patient is eating almost 1,000 more calories than recommended contributing to his obesity |

|(United States Department of Agriculture, 2013). This patient needs to lower his BMI to help improve all of his medical conditions (Osborn et al., 2014). |

|With weight loss the patient can improve his status of obesity, hypertension, diabetes, dyslipidemia, and congestive heart failure (Osborn et al., 2014). |

|References |

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|Osborn, K., Wraa, C., Watson, A., & Holleran, R. (Eds.). (2014). Medical-surgical nursing: |

|Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson. |

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|United States Department of Agriculture. (2013). SuperTracker. United States Department of Agriculture. Retrieved from |

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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? “My family and my church family help me.” |

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

|“Stress…I just pray about it and try to not let it worry me. Music or writing poetry calms me. I try to get back to healthy emotion by thinking of some positives |

|that can cur of rectify the situation. I look for a resolution.” |

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

|“A couple of different difficult things have been happening… with the illness it can’t always be great. It’s either feast or famine. Work and relationships are a |

|struggle. Lately, I’ve just focused on getting me better. Being the best I can be for myself and not someone else.” |

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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? “Yes, in football.” Have you ever been hit punched or slapped? “Yes.” |

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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?  “N/A” |

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|Are you currently in a safe relationship? “No 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: |

| |

|Generativity vs. Stagnation is the developmental stage for this patient. Generativity is the stage that displays generating, nurturing, positively influencing, or |

|creating things that will outlast them. The example from the article alludes to contributing to society or having children. Stagnation is the opposite; it is a |

|failure to contribute to society. These people tend to feel disconnected and uninvolved (Cherry, n.d.). |

| |

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

|My patient was definitely in the psychosocial generativity stage of development. I came to this determination because he is a spokesman against bullying. He |

|travels from school to school in Hillsborough county presenting power point presentations, songs, and dresses up as “Bogie Bear” to stop bullying. My patient shows|

|obvious signs of nurturing, positively influencing, and contributing to society. |

| |

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

|The disease has motivated my patient to improve his generativity psychosocial stage. He spoke of focusing on himself to get better as well as continuing to going |

|out in the community and stop bullying. My patient was not discouraged by his medical conditions, he was using the experience as a learning opportunity to improve |

|his own health and teach his children better lifestyle choices. |

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|References |

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|Cherry, K. (n.d.). Generativity Versus Stagnation. About Psychology. Retrieved from |

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|+3 CULTURAL ASSESSMENT: |

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

|“Education. From the start, as a youth, our culture is an eat to survive or an eat to be healthy. We ate what we had. We ate all the pig with the salt and sodium. |

|Economics has something to do with it. It was eat up, and the more the merry for me. I didn’t have the resources to know what was good food and what was bad food. |

|It’s a lack of education.” |

|What does your illness mean to you? |

|“I didn’t have portion control, I can save money and buy more food, and that’s what I knew and how I was raised.” |

|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

| |

|Have you ever been sexually active? “Yes.” |

|Do you prefer women, men or both genders? “Women.” |

|Are you aware of ever having a sexually transmitted infection? “Yes.” |

|Have you or a partner ever had an abnormal pap smear? N/A |

|Have you or your partner received the Gardasil (HPV) vaccination? N/A |

| |

|Are you currently sexually active? “No.” If yes, are you in a monogamous relationship? “N/A” |

|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? “I try to be as cautions as I can. |

|I look out for myself and trust the other person would be honest with me.” |

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|How long have you been with your current partner? “N/A” |

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|Have any medical or surgical conditions changed your ability to have sexual activity? “Yes, the diabetes.” |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? “No, not concerned at all.” |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

“It’s first. Everything is built around my belief.”

Do your religious beliefs influence your current condition?

“No…well, wait a minute… it’s helping me get out of this situation.”

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

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

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

| | |(age thru ) |

| | | |

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

| | | |

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

|“Yes, they try to go outside when some cigarettes. I would say they smoke about a |If yes, what did they use to try to quit? |

|pack a day.” | |

| |

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

| What? Patient used to drink beer socially. |How much? 3 |For how many years? 13 |

| |Volume: cans |(age 35 thru 48) |

| |Frequency: Patient used to drink 2x a month during | |

| |football season. | |

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

|The patient quit one year ago. | | |

| |

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

| If so, what? |

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

| | |(age thru ) |

| | | |

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

| | | |

| | | |

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

|Patient states that he has not been exposed to any occupational or environmental hazard or risks. |

| |

| |

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

|N/A |

| |

| |

| |

| |

( 10 Review of Systems Narrative

| |Gastrointestinal |Immunologic |

| | Nausea, vomiting, or diarrhea | Chills with severe shaking |

|Integumentary | Constipation Irritable Bowel | Night sweats |

| | |Patient states that he sweats often during the night. |

| Changes in appearance of skin | GERD Cholecystitis | Fever |

|Patient states that the skin on his feet is darkening.| | |

| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |

| Dandruff | Hemorrhoids Blood in the stool | Lupus |

| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |

| Hives or rashes | Pancreatitis | Sarcoidosis |

| Skin infections | Colitis | Tumor |

| Use of sunscreen SPF: | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: |Appendicitis | Enlarged lymph nodes |

|Other: | Abdominal Abscess |Other: |

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

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

|Patient wears corrective glasses | | |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| |Patient states that he gets up to urinate during the | |

| |night 3-4x. | |

| 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: 12 x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

| Routine brushing of teeth 1 x/day | | Diabetes Type: 2 |

| Routine dentist visits | | Hypothyroid /Hyperthyroid |

|Patient states that he visits the dentist as needed. | | |

|Vision screening | | Intolerance to hot or cold |

|Patient states that he gets his eyes examined yearly. | | |

|Other: | | Osteoporosis |

| | |Other: |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

|Patient states that he has difficulty breathing due to| | |

|his recent CHF, PE, hypertrophic heart size, and his | | |

|overweight status. | | |

| Cough - dry or productive |Women Only | CVA |

|Patient states that his cough initiates with deep | | |

|breathing and is treated by inhalers and breathing | | |

|treatments. | | |

| Asthma | Infection of the female genitalia | Dizziness |

| | |Patient states that he feels dizzy as a response to |

| | |hypoglycemia. |

| 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 |

| | |Patient states that he feels tremors as a response to |

| | |hypoglycemia. |

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? 01-19-2016 | menopause age? | Meningitis |

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

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

|Cardiovascular |Men Only |Mental Illness |

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

|Patient was diagnosed with HTN in 2014 | | |

| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |

|Patient was diagnosed in 2014 | | |

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

|Patient has chest pain resolving post PE. | | |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: |

|CHF |Musculoskeletal | |

|Patient was diagnosed with CHF this admission. | | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? 01-19-2016 |Arthritis | Chicken Pox |

|Other: |Other: Patient is experiencing diabetic peripheral |Other: |

| |neuropathy in his lower extremities and he is feeling | |

| |numbness and tingling. | |

| | | |

|General Constitution |

|Recent weight loss or gain |

|How many lbs? |

|Time frame? |

|Intentional? |

|How do you view your overall health? |

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

|N/A. |

| |

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

|Patient states that he does not have any additional questions or comments. |

|±10 PHYSICAL EXAMINATION: |

| |

|General Survey: Patient is awake, alert, and oriented to time, place, and person. |

|Height 193.04 cm/76in |

|Weight: 137 kg |

|BMI: 37 |

|Pain: (include rating and location) |

| |

|Patient is having chest pain at a 5 on a scale 0-10. |

| |

| |

|Pulse: 71 |

|Blood Pressure: (include location) |

|128/84 LAC |

| |

| |

| |

|Respirations: 17 |

| |

| |

| |

|Temperature: (route taken?) 98% orally |

|SpO2 |

|99% |

|Is the patient on Room Air or O2 |

| |

| |

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

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

| |

| |

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

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

| |

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

| clear, crisp diction |

| |

|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: Location: Date inserted: |

|Fluids infusing? no yes - what? Heparin infusion from the LAC with a 22G and 1.0in length that was inserted 01-23-2016 |

| |

|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 Left and Right 2 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: Patient’s teeth were clean, yellowed, with gold cap on a tooth of right side |

|Comments: |

| |

|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 D LLL D |

|RLL D |

| |

|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) |

|I did not realize I forgot the strip for this section but now it’s too late. I apologize for forgetting. |

| |

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

| |

|Apical pulse: 2 (difficulty assessing due to obesity) Carotid: 3 Brachial: 3 Radial: 3 Femoral: not assessed |

|Popliteal: not assessed DP: 2 PT: 2 |

| |

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

| |

|Location of edema: pitting 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 01 / 25 / 16 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

| |

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

| |

|Nausea emesis Describe if present: |

| |

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

| |

|Other – Describe: |

| |

| |

| |

|GU Urine output: Clear Cloudy Color: Yellow Previous 24 hour output: 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: 5/5 RUE, 5/5 LUE, 5/5 RLE & 5/5 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 |

| |

|Patient has diabetic peripheral neuropathy, and mild 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 except on the lower extremities, he can feel vibration but not light touch from |

|the ankle down to toes. 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: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative |

|Deep tendon reflexes were not assessed due to lack of assessment tools. |

| |

| |

|±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 |

| |

|PT |

|01-24-2016 |

|01-25-2016 |

|01-26-2016 |

| |

|10.8 |

|10.9 |

|11.1 |

| |

|(10-13seconds is normal) |

|The patient’s PT (prothrombin time) value is trending up indicating that the patient will take longer to clot. This is beneficial to avoid clotting and is reported |

|in seconds. Both the PT and INR below, are monitored as an indication of the effects of warfarin. |

| |

|INR |

|01-24-2016 |

|01-25-2016 |

|01-26-2016 |

| |

|0.9 |

|0.9 |

|1.0 |

| |

|( ................
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