UNIVERSITY OF SOUTH FLORIDA



-UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Michelle Scarlett |

|Patient Assessment Tool . |Assignment Date : 9/10/13 |

| ( 1 PATIENT INFORMATION |Agency: FHT |

|Patient Initials: C.H.B. |Age: 78 |Admission Date: 8/31/13 |

|Gender: Male |Marital Status: married |Primary Medical Diagnosis with ICD-10 code: |

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|6+6+++Male | | |

|Primary Language: English |2014 ICD-10-CM I35.0 Non-rheumatic aortic (valve) stenosis |

|Level of Education: college |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Finance |Coronary Artery Disease with LAD lesions |

|Number/ages children/siblings: Children: M-51, M-49, F-45, sisters-87 & 68 |Mild congestive heart failure, Atrial Fibrillation |

| |Chronic shoulder pain and chronic arthritis |

|Served/Veteran: Marine Corp |Code Status: FULL |

|Living Arrangements: House with wife |Advanced Directives: YES |

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

| |Surgery Date: 9/4/2013 Procedure: Aortic Valve |

| |Replacement |

|Culture/ Ethnicity /Nationality: Irish/Scottish | |

|Religion: Pentecostal |Type of Insurance: Medicare: Humana |

|( 1 CHIEF COMPLAINT: |

|“For the last week I have been experiencing shortness of breath that doesn’t seem to be getting better.” |

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

|Patient is a 78 year old active senior who has a history of Atrial Fibrillation. Patient stated that is new onset of symptoms began on 8/28/2013 with SOB. Patient |

|described that the SOB was constant and appeared to be getting worse than better. He stated that he felt as if he couldn’t catch a breath and that the severity was|

|possible above a 10. His symptom was aggravated upon exertion and relieve upon rest. He sought assistance from his primary doctor and was referred to Bayonet Point|

|Hospital, at which he received oxygen therapy. He was further assessed and found to be in congestive heart failure. His echo showed an aortic valve of 0.57 cm^2. |

|Patient cardiac catheterization showed that he had critical aortic stenosis and coronary artery disease proximal his left anterior descending artery. Patient was |

|transferred on 9/30/2013 to Florida Hospital Tampa for a possible Transcatheter Aortic Valve Replacement (TAVR). However, instead of a TAVR it was suggested that |

|patient would benefit more from an open heart surgery. |

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

|Date |Operation or Illness |

|1980’s |Hypertension |

|1990’s |Chronic Kidney Disease |

|2013 |Atrial Fibrillation |

|2013 |Congestive Heart Failure |

|2013 |Aortic Stenosis |

|2013 |Coronary artery disease |

|2013 |Chronic shoulder pain |

|2013 |Chronic arthritis |

|( 2 FAMILY MEDICAL 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) | | |

|Influenza (flu) (Date) | | |

|Pneumococcal (pneumonia) (Date) | | |

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

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

|REACTIONS |Causative Agent | |

|Medications |NKA | |

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| |N/A |N/A |

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

|etc.) | | |

| |N/A |N/A |

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

|genetic factors impacting the diagnosis, prognosis or treatment) |

| Aortic Stenosis is the narrowing of your aortic valve. This condition is very serious because it interrupts blood |

|flow into the aorta throughout the other valves of the heart and the rest of your body. The body is therefore, forced to keep up with blood flow, which can cause |

|chest pain, weakness and shortness of breath for the individual affected. Risk factors for the disease include genetics, gender, especially male, and having |

|certain diseases such as, rheumatic fever, which can damage the leaflets of the aortic valve. Aortic Stenosis can be diagnose by a physical exam by your |

|cardiologist or by medical imaging test such as, a chest x-ray, CT scan MR, and or a cardiac catheterization. Aortic Stenosis is usually treated by way of surgery,|

|for example open heart surgery. The prognosis is pretty good considering other factors such as, how long the patient has been living with the disorder. |

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

|Name Albuterol |Concentration (mg/ml) N/A |Dosage Amount (mg) 2.5 mg |

|Route Nose |Frequency Q4H |

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

|Indication: Used to control of prevent airway obstruction caused by COPD or bronchospasm. |

|Side effects/Nursing considerations: S/E-Restlessness, N/V, and tremor, Hyperactivity in children. Nurse-Watch out for wheezing due to excess use of inhaler. If |

|wheezing is present contact physician. Monitor pulmonary function test before administration and periodically, assess lungs, BP and pulse before and during |

|administration. |

| |

|Name Aspirin |Concentration N/A |Dosage Amount 325 mg |

|Route Oral |Frequency Daily |

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

|Indication: ischemic attacks, MI, mild to moderate pain and inflammatory disorders such as osteoarthritis |

|Side effects/Nursing considerations: S/E- Tinnitus, GI Bleed, anaphylaxis and laryngeal edema. Nurse- Watch for bleeding and use cautiously in people with renal |

|disease. May cause Reyes syndrome in children. Watch for hypersensitive reactions and monitor lab values such as serum salicylate and serum uric acid. |

| |

|Name Carvedilol |Concentration N/A |Dosage Amount 3.125 mg |

|Route: Oral |Frequency BID |

|Pharmaceutical class: Beta- blockers |Home Hospital or Both X |

|Indication: Hypertension and also heart failure with other medications like digoxin |

|Side effects/Nursing considerations: S/E- fatigue, insomnia, memory loss, low heart rate, pulmonary edema, stevens-johnson syndrome, anaphylaxis and angioedema. |

|Nurse- Watch for drug to drug interactions like clonidine which can increase hypotension and bradycardia. Monitor BP, pulse, I&O regularly. Labs to consider are |

|BUN, potassium, uric acid, triglyceride and serum lipoprotein. |

|Name Enoxaparin |Concentration N/A |Dosage Amount 40 mg |

|Route Subcutaneous |Frequency Daily |

|Pharmaceutical class: Antithrombotics/LMWH |Home Hospital X or Both |

|Indication: Prevention of DVT, VTE and PE, treat acute MI |

|Side effects/Nursing considerations: S/E- dizziness, constipation, hyperkalemia and anemia. Nurse- Use cautiously in patients with renal disease, uncontrolled |

|hypertension, and those with a bleeding history. Watch for bleeding and hypersensitivity and report signs to physician. Labs to monitor, CBC, platelet, possible |

|aPTT and stools for occult blood. Protamine sulfate 1mg for each enoxaparin used to reverse toxicity. |

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|Name Furosemide |Concentration N/A |Dosage Amount 40 mg |

|Route Oral |Frequency Daily |

|Pharmaceutical class: Loop Diuretics |Home Hospital X or Both |

|Indication: Hypertension, hepatic impairment or renal disease, edema as a result of heart failure |

|Side effects/Nursing considerations: S/E- blurred vision, vertigo, tinnitus, constipation, excessive urination, stevens-johnson syndrome, toxic epidermal |

|necrolysis, aplastic anemia and agranulocytosis. Nurse- watch for drug to drug interactions such as NSAID, which decreases the effects of furosemide. Patient can |

|also become hypokalemic, and at increased risk for digoxin toxicity. Monitor I&O, daily weight, edema, lungs, BP and pulse. Notify physician if patient has dry |

|mouth, weakness, hypotension and oliguria. Labs to monitor are electrolytes, serum glucose, uric acid levels and renal/hepatic functions. |

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|Name Lisinopril |Concentration N/A |Dosage Amount 2.5 mg |

|Route Oral |Frequency Daily |

|Pharmaceutical class Ace Inhibitor |Home Hospital or Both X |

|Indication: Hypertension and heart failure |

|Side effects/Nursing considerations: S/E- dizziness, hypotension, erectile dysfunction, cough and angioedema. Nurse- use cautiously in patients with renal failure |

|and women of child bearing age. Watch for drug interaction with NSAIDS and selective COX-2-inhibitors. Monitor fluids, weight, BP and pulse. Notify physician of |

|significant changes such as angioedema, rales and crackles. Labs to monitor CBC, BUN, AST, ALT, serum bilirubin and alkaline phosphatase. |

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|Name Pantroprazole |Concentration N/A |Dosage Amount 40 mg |

|Route Oral |Frequency Daily |

|Pharmaceutical class: Proton Pump Inhibitor |Home Hospital X or Both |

|Indication: GERD |

|Side effects/Nursing considerations: S/E- diarrhea, constipation, N/V, rash and headaches. Long term use can put patient at risk for bone fractures. Nurse- Patient|

|should take whole tablet 30 minutes before meals for full effectiveness. Watch out for drug to drug interaction such as digoxin toxicity. Assess patient routinely|

|for emesis, epigastric or abdominal pain, and blood in stool. Labs to check are AST, ALT, bilirubin and alkaline phosphatase. |

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|Name Potassium Chloride |Concentration N/A |Dosage Amount 20 mEq |

|Route Oral |Frequency Daily |

|Pharmaceutical class: Mineral and Electrolyte replacements/supplements |Home Hospital X or Both |

|Indication: Prevention/treatment of hypokalemia |

|Side effects/Nursing considerations. S/E- confusion, weakness, arrhythmias, ECG changes, N/V, parylsis and paresthesia. Nurse- Use cautiously in patients with |

|renal impairment, cardiac disease, diabetes mellitus and hypomagnesemia. Patients at risk for hyperkalemia if used with blood pressure meds such as, potassium |

|sparing diuretics. Labs include serum potassium, serum chloride, serum bicarbonate, and renal function. Sodium bicarbonate can be used to correct toxicity of |

|hyperkalemia. |

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|Name Simvastatin |Concentration N/A |Dosage Amount 10 mg |

|Route Oral |Frequency QHS |

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

|Indication: Hypercholesterolemia, MI, coronary revascularization and stroke |

|Side effects/Nursing considerations: S/E- Abdominal cramps, constipation, drug-induced hepatitis, dizziness, heartburn, erectile dysfunction, rashes, |

|rhabdomyolysis. Nurse- Use cautiously in patients with liver and renal disease. Watch for drug to drug interactions such as, myopathy with concurrent use of |

|amiodarone and niacin. Ask patient about diet in regards to fat consumption amount. Labs to monitor are liver function test, for example AST before and 6-12 weeks |

|after initiation and every 6 months to check levels stay within normal limits. CPK should also be monitored if patient complains of muscle tenderness. |

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|Name Insulin Lispro |Concentration N/A |Dosage Amount Medium dose |

|Route Subcutaneous |Frequency ACHS |

|Pharmaceutical class Pancreatics |Home Hospital X or Both |

|Indication Manage hyperglycemia for Type 1 and Type 2 diabetes mellitus |

|Side effects/Nursing considerations: S/E- hypoglycemia, redness and swelling at the site, anaphylaxis. Nurse- use cautiously in renal and hepatic impaired |

|patients. Regularly monitor patients for symptoms of hypoglycemia and hyperglycemia r. Monitor patient’s weight as it may affect insulin dose. Labs to monitor |

|include blood glucose every 4-6 hours or more often as needed as in the case of ketoacidosis. A1C every 3-6 months to determine usefulness of drug. |

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|Reference: UnboundMedicine. (2013). David’s drug guide. Retrieved from |

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

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

|Diet pt follows at home? Regular diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |Patient appears to be incorporating some heart healthy foods in his diet by |

| |eating fruits, seafood and nuts. However, he needs to become more serious about |

| |eating more frequent smaller meals that will provide him the energy and strength |

| |that his muscles and heart needs to keep him going. Things for patient to |

| |consider in following a heart healthy diet are portion size of food eaten, |

| |polyunsaturated and monounsaturated fats, incorporating more fruits and vegetable|

| |and whole grains and limiting sodium, unhealthy fat and foods high in |

| |cholesterol. Therefore, for breakfast patient needs to consider limiting salt |

| |intake for his scramble eggs and consider adding grains such as oatmeal, whole |

| |wheat toast and whole wheat cereal with fat-free or low fat free milk, cheese and|

| |yogurt. For lunch he should eat lean sandwich meats with whole wheat bread, |

| |steamed green leafy vegetables and fruit fresh or dry. For dinner patient’s |

| |choice of seafood is a good option. However, it can go wrong if sodium and |

| |cholesterol is not taken into consideration. Therefore, patient needs to consider|

| |cooking in olive oil, and being light on the seasoning, using things like garlic |

| |to influence flavor. Steamed salmon and chicken with brown rice, and vegetables |

| |served in the right portion and calories is a great start towards a healthy diet.|

| |As for fluids patient needs to drink plenty of water throughout the day and do at|

| |least one physical activity such as, walking to stay physical active and strong. |

| |According to my the recommended number of servings of grains daily |

| |should be 6oz, 2.5 cups of vegetables daily, 2 cups of fresh or frozen fruits, 3 |

| |cups of low-fat, or fat free milk and other milk products and 5.5 oz daily of |

| |low-fat or lean meats and poultry that is either broiled or baked. Based on these|

| |recommendations patient should have a great start in moving forward with a new |

| |and improve heart healthy diet. |

|Breakfast: 10 a.m.-seasoned scrambled eggs, cheese, and | |

|Toast. | |

|Lunch:12:00 p.m.-1:30 p.m- A sandwich such as ham | |

|Sandwich. | |

|Dinner: Seafood, such as Salmon with rice and veggies. | |

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|Snacks: Trail mix, dry fruit, and walnuts | |

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|Liquids (include alcohol): coffee, juice, wine and water. | |

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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 reference. |

| |Reference-United States Department of Agriculture. (2011). What’s on your plate? |

| |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 wife” |

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|How do you generally cope with stress? or What do you do when you are upset? “I holler and scream.” |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) “No everyone |

|gets along.” |

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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.” |

| |

|Have you ever felt unsafe in a close relationship? _________No______________________________________________ |

| |

|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?  ______N/A |

|Are you currently in a safe relationship? Yes |

| |

|( 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: Patient is in the age group of ego integrity versus despair. Ego integrity is a feeling of fulfillment regarding one’s life. Despair is having |

|a feeling of regret and a need to want to do things differently to change one’s life. Where integrity can lead to joy and happiness, despair can lead to depression |

|and a feeling of disappointment. |

| |

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

| This patient is in Ego Integrity stage. He is very positive about life despite the risky surgery he just went |

|through. He lives life to the fullest by giving back to his community. He is very active in church and sharing his |

|religion. He is a family man that is proud about his life with his wife, despite that this is his second marriage. He is |

|A proud father, a proud veteran and most of all a proud man who hopes to get back strong and continue to share |

|of himself. |

| |

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

|“My disease has slowed me down but I believe that God has fixed my heart to get back out and witness to people.” |

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|+3 CULTURAL ASSESSMENT: |

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

|What does your illness mean to you? “God has something else for me because I could have died very easily.” |

|+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? _________No__________________ |

|Have you or a partner ever had an abnormal pap smear?__N/A_______________________________ Have you or your partner received the Gardasil (HPV) vaccination? |

|__________________No___________________ |

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|Are you currently sexually active?   _____________yes______________When sexually active, what measures do you take to prevent acquiring a sexually transmitted |

|disease or an unintended pregnancy? _________none_________________________ |

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|How long have you been with your current partner?__8 years_____________ |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  “Not until now.” |

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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?

_________My religion and spirituality is everything to me. My marriage is Christ centered.____

______________________________________________________________________________________________________

Do your religious beliefs influence your current condition?

__________________________________Yes, it gives me hope._________________________

______________________________________________________________________________________________________

|+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? Cigarettes |How much?(specify daily amount) |For how many years? 38 years |

| |2.5 pack a day |(age 20 thru 58 ) |

|Pack Years: 95 pack years | |If applicable, when did the patient quit? |

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

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

| What? wine |How much? (give specific volume) |For how many years?60 years |

| |A glass of wine on special occasions |(age 18 thru current ) |

| If applicable, when did the patient quit? | N/A | |

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

| If so, what? N/A |

| |How much? N/A |For how many years? N/A |

| | |(age thru ) N/A |

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

|N/A | | |

| |N/A | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? No |

| |

( 10 Review of Systems

|General Constitution |Gastrointestinal |Immunologic |

| Recent weight loss or gain 35lbs | 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 No SPF: N/A | Diverticulitis | Life threatening allergic reaction |

|Bathing routine: Once a day |Appendicitis | Enlarged lymph nodes |

|Other: N/A | Abdominal Abscess |Other: |

| | Last colonoscopy? 2008 | |

|HEENT |Other: |Hematologic/Oncologic |

| Difficulty seeing |Genitourinary | Anemia |

| Cataracts or Glaucoma | nocturia | Bleeds easily |

| Difficulty hearing | dysuria | Bruises easily |

| Ear infections | hematuria | Cancer |

| Sinus pain or infections | polyuria | Blood Transfusions |

|Nose bleeds | kidney stones |Blood type if known: |

| Post-nasal drip |Normal frequency of urination: 10 x/day |Other: |

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

| Dental problems | |Metabolic/Endocrine |

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

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

|Vision screening 1 year | | Intolerance to hot or cold |

|Other: N/A | | Osteoporosis |

| | |Other: N/A |

|Pulmonary | | |

| Difficulty Breathing | |Central Nervous System |

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

| Asthma | Infection of the female genitalia | Dizziness |

| Bronchitis | Monthly self breast exam | Severe Headaches |

| Emphysema | Frequency of pap/pelvic exam | Migraines |

| Pneumonia | Date of last gyn exam? | Seizures |

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

| Environmental allergies | menarche age? | Encephalitis |

|last CXR? 9/10/2013 | menopause age? | Meningitis |

|Other: N/A |Date of last Mammogram &Result: |Other: N/A |

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

|Cardiovascular |Men Only |Mental Illness |

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

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

| Chest pain / Angina | Date of last prostate exam? 8/20/2013 | Anxiety |

|Myocardial Infarction | BPH | Bipolar |

| CAD/PVD |Urinary Retention |Other: N/A |

|CHF |Musculoskeletal | |

|Murmur | Injuries or Fractures |Childhood Diseases |

| Thrombus | Weakness | Measles |

|Rheumatic Fever | Pain | Mumps |

| Myocarditis | Gout | Polio |

| Arrhythmias | Osteomyelitis | Scarlet Fever |

| Last EKG screening, when? 9/10/2013 |Arthritis | Chicken Pox |

|Other: N/A |Other: N/A |Other: N/A |

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

|No |

|Any other questions or comments that your patient would like you to know? No |

|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |

|General Survey: Patient is a gracefully |Height: 179 cm |Weight: 81.1 kg BMI: 25.3 |Pain: (include rating & location) |

|mature 78 y/o male with an optimistic | | |0 |

|view post-valve replacement surgery. | | | |

| |Pulse: 90 |Blood | |

| | |Pressure:109/50 | |

| | |(include location) | |

|Temperature: (route taken?) |Respirations:16 | | |

| | | | |

|98.4 (oral) | | | |

| |SpO2 100 |Is the patient on Room Air or O2: Room air |

|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 | |

| | |

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| | |

| | |

| Peripheral IV site Type: Location: Date inserted |

| no redness, edema, or discharge |

| Fluids infusing? no yes - what? |

|Central access device Type: Left Location: Jugular Date inserted: 9/3/13 |

| |

|Fluids infusing? no yes – what? |

| |

|HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline |

| Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge |

| Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |

| PERRLA pupil size /3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus |

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

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

|Dentition: |

|Comments: Did not have tools to measure the inches of each ear for the whisper test. |

| |

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

| | | Lungs clear to auscultation in all fields without adventitious sounds |

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

| |WH – Wheezes |Sputum production: thick thin Amount: scant small moderate large |

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

| |RH – Rhonchi | Crackles and bibasilar rales were previously noted in patient’s lungs. |

| |D – Diminished | Unable to percuss lungs due to post op bandages. |

| |S – Stridor | |

| |Ab - Absent | |

| | | |

| | | |

|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th intercostal space midclavicular line. |

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

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

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

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

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

|Location of edema: N/A pitting non-pitting |

|Extremities warm with capillary refill less than 3 seconds |

| |

|GI/GU: 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 |

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

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

|CVA punch without rebound tenderness |

|Last BM: (date 9 / 9 / 13 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |

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

|Hemoccult positive / negative (leave blank if not done) |

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

| Other – Describe. |

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

|Strength bilaterally equal at _____3__ RUE ______3_ LUE ___3____ RLE & _3______ in LLE |

|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |

|vertebral column without kyphosis or scoliosis |

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

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

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

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

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

|Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: positive negative Babinski: |

|positive negative |

|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

|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 |

| |

|Glucose =81 |

|(Normal 60-100) |

|9/2/2013-9/9/2013 |

|Patient’s glucose has been within normal limits for the dates reviewed. |

|Patient receives daily insulin lispro which has been effective in keeping his blood glucose within normal limits. |

| |

|Sodium=133L |

|(Normal 135-145) |

| |

| |

| |

|9/2/2013-9/9/2013 |

|Patient’s sodium has been fluctuating since admission between being under or within the normal limits. Patient’s last sodium level is 2 points below the norm. |

|Sodium can cause the body the body to hold on to too much water, which can cause respiratory problems as well as heart problems overtime. So Staying in normal range |

|is very vital for this patient. |

| |

| |

|Potassium=3.7 (Normal 3.5-5) |

|Calcium=7.6L (8.5-10.3) |

|Chloride=102 (95-108) |

|9/2/2013-9/9/2013 |

|Patient’s calcium is lower than normal and lower than his other electrolytes but his calcium as been closer to the norm since admission of 8.6. |

|This calcium imbalance is indicative of patient’s CHF. I could also mean possible bone break down for patient considering his age. Therefore adequate adjustments of |

|calcium amount in his diet is very important in keeping patients levels within the norm. |

| |

| |

|CO2=23L (Normal 35-45 ) |

| |

| |

|9/2/2013-9/9/2013 |

|Patient’s CO2 has been between 23 and 27 since admission. |

|CO2 needs to be monitored so that patient blood doesn’t become too acidic causing further respiratory problems and increased pressure on his heart. |

| |

|BUN=21H (normal-6-20) |

|Creatinine =1 (normal 0.6-1.1) |

|GFR=73 (60-90) |

|9/2/2013-9/9/2013 |

|Patient’s BUN is a little higher than usual, indicating kidney problems and CHF. His creatinine is within normal limits but has been as high as 1.9. His GFR is |

|within normal limits and has been relatively the same throughout his stay. |

|These values needs close monitoring due to patients history of kidney disease and CHF. |

| |

|RBC=2.74L (Normal 4.2-5.4) |

| |

|HGB=8.3L(Normal 12-16) |

| |

|HCT=25.2L (normal 38-47) |

|WBC=11.4H (Normal 3.5-10.5 |

|Platelet=189 (150-450) |

| |

|RDW=14.2 (normal 11-15) |

|MCV=92 (normal 76-100) |

|MCH=30 (normal 27-33) |

|MCHC=33 (normal 33-37) |

|MPV=11.6 (normal 7.5-11.5) |

|9/2/2013-9/9/2013 |

|Patient’s WBC has been low since admission, as low as 9.5. His RBC, HGB and HCT are lower than normal. Possibly due to the amount of blood lost during and |

|post-surgery. Past HGB has been 13.5 and past HCT has been 42.2. |

|Patient’s WBC indicates presence of infection. |

|Close monitoring of patient’s CBC’s, regarding the need for blood transfusion for patient due to such low levels like the HGB. Patient is at risk for anemia |

| |

|Chest x- ray |

|Echocardiogram |

|9/2/2013 |

|x-ray showed mild bilateral pleural effusion |

|Echo showed an EF of 35% and severe chronic aortic stenosis that could be life threatening |

|The diagnostic test indicated the immediate need of surgery for patient. |

| |

| |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accuchecks, etc. Also provide rationale and frequency|

|if applicable.) |

|Heart healthy diet, daily monitoring of vitals, labs, and diagnostic tests. Consult with cardiologist regarding surgery suggestion and post opt care including |

|decreasing patient’s risk for pulmonary complications . Accuchecks before each meal. |

| |

| |

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

|Activity intolerance related to imbalance between oxygen supply and demand as evidenced by not being able to |

| ambulate for a long period of time. |

| |

|Decreased cardiac output related to aortic stenosis as evidence by changes in heart rhythm and rate. |

| |

| 3. Knowledge deficit related to lack of understanding of cardiac function as evidence by stating concerns |

| regarding care post- surgery. |

± 15 CARE PLAN

Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by not being able to ambulate for a long period of time.

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

| | |Provide References | |

|Patient will demonstrate increased activity tolerance|Check vital signs before and immediately after |Patient may experience complications such as |Patient’s blood pressure signs were stable during |

|by end of shift and by discharge. |activity, especially since patient is on diuretics |orthostatic hypotension related to medications, like |rest and high during periods of ambulation. His |

| |and beta-blockers. |diuretics which, can cause fluid shift. |oxygen saturation also dropped while ambulating. |

| |Provide assistance with self-care activities with |These actions reduces patient need for excess oxygen,|Patient requested pain medication before ambulation |

| |periods of rest and pain management in ambulating |and pain medication and also reduces stress on the |for his own peace of mind. Even though patient was |

| |around the nurses’ station at least once today. |patient’s heart in making sure that he is not being |determined to push himself periods of rest were taken|

| | |more active than he can tolerate. |to ensure increased tolerance in achieving the goal |

| | | |for the day. In the end patient was quite satisfied |

| | | |with his accomplishment. |

| |Evaluate accelerating activity tolerance and |Keeping track of patient’s progress will indicate |Patient became intolerant of activity due to |

| |intolerance throughout shift and throughout recovery.|options to increase activity level or consult further|emotional anxiety of wanting to push himself above |

| | |with patient’s cardiologist and respiratory therapist|treatment protocols. Therefore, recurrent explanation|

| | |for alterations in patient’s care. |and monitoring of activities had to be enforced to |

| | | |ensure safety and tolerance. |

± 15 CARE PLAN

Nursing Diagnosis: Decreased cardiac output related to aortic stenosis as evidence by changes in heart rhythm and rate.

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

| | |Provide References | |

|To recognize signs and symptoms of decreased cardiac |Assess mentation every two hours, monitor heart rate |Restlessness and sinus tachycardia are early signs of |Restlessness was not observed during shift with |

|output to assess patient’s progress in his recovery |and sounds, lung sounds and BP every 3-4 hrs during |decreased cardiac output. S3 sounds are signs of left |patient. His heart rate even though increased during |

|period and intervene as needed. |shift as well as to identify changes such as |ventricular failure. Crackles reflect fluid |ambulation stayed within normal range. No extra heart |

| |restlessness and tachycardia. |accumulation in the lungs. |or lung sounds were found during shift |

| | Assess skin color, temperature and pulses during |Cold clammy skin and weak pulses are early signs of |Patient’s skin color, temperature and pulses were also|

| |hourly rounding. |decreased cardiac output and the need for immediate |documented to be within normal limits. |

| | |intervention. | |

| |Assess patient’s response to increased activity during|Increasing activity can place high demands on the |Patient did not respond well to increase activity as |

| |ambulation and indication of chest pain during hourly |heart. Therefore if patient experiences shortness of |he experienced SOB and fatigue in wanting to push |

| |rounding. |breath and fatigue then these are indicative of low |himself faster that suggested. No chest pains were |

| | |cardiac output. Chest pains states that there is an |reported as patient was provided direct supervision on|

| | |imbalance between the demand and supply of oxygen. |when to rest or proceed with activities. |

± 15 CARE PLAN

Nursing Diagnosis: Knowledge deficit related to lack of understanding of cardiac function as evidence by stating concerns regarding care post- surgery.

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

| | |Provide References | |

|Increase patient’s knowledge of his disease and |Provide an overview of normal heart function and how |Understanding of the heart function and disease |Patient was appreciative of the review and spoke |

| |to recognize changes that indicates problems with the|process that has occurred with client will encourage |about the time he began to notice changes with his |

| |normal functioning of the heart by end of shift and |adherence of treatment plan. |cardiac functions. |

| |the days up to discharge. | | |

| |Review medication with client including purpose and |Understanding medications and prompt reporting of |Patient and his wife are very adamant about keeping |

| |possible side effects to be aware of during each |side effects can prevent occurrence of unreported of |records of his medications along with his doctor |

| |administration and again by discharge. |drug-related complications. |visits. Therefore, they were attentive to the |

| | | |information provided and ask for clarification when |

| | | |needed. |

| |Review signs/symptoms that require immediate medical |Encouragement of self-monitoring care influences |Patient explained that the shortness of breath is |

| |attention, such as fever, shortness of breath and |patient’s involvement and awareness in maintaining |what alerted him to seek immediate attention and he |

| |rapid weight gain by end of shift and by discharge. |proper health. |was glad that he did. He also made a note of other |

| | | |signs and symptoms he needs to be aware of and the |

| | | |instances to seek immediate help. |

|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Patient will be encouraged to avoid exposure to secondary smoke, the importance of eating a|

|heart healthy diet, following an exercise plan, elevating lower extremities and HOB of the bed 30 degrees or higher, monitoring weight, monitoring blood pressure, monitoring pulse, and taking prescribed meds as |

|directed. |

|Consider the following needs: |

|□SS Consult |

|□Dietary Consult- Patient will be provided dietary consult within the hospital that will be followed outside beyond discharge to improve respiratory and cardiac health as well as ensure proper muscular and bone health|

|as patient is in his 70’s. Dietary consult will include heart healthy choices suggested by . |

|□PT/ OT-N/A |

|□Pastoral Care N/A |

|+□Durable Medical Needs – Patient needs to discuss with a case manager the need for possibly a four legged walker and or cane to assist with ambulation within and outside the home. |

|□F/U appts – Patient will follow up with primary care doctor 1 week after discharge to discuss self-management of the disease and other illnesses be evaluated for significant changes or improvement regarding |

|respiratory, blood pressure, kidney functioning, and cardiac health.. Also to discuss any new symptoms or other health concerns that arises since discharge and during his follow up visit. |

|□Med Instruction/Prescription - Patient will be provided detailed instructions of discharge plan and proper self-administration of medications upon discharge by demonstrating back to the nurse the information learned.|

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No Patient will be provided local resources to get medications at a discounted cost to him. |

|□Rehab/ HH – Patient will be provided the options of care for rehab or home health and that the options are based on his healing process. Contact personnel’s information will be provided to patient once collaboration |

|has been made with him and his wife regarding plans of care. |

|□Palliative Care N/A |

References

Ackley, B.J. & Ladwig, G.B. (2007). Nursing Diagnosis Handbook: An Evidenced-Based Guide to Planning

Care (8th ed.). St. Louis: Mosby/Elsevier. (pg 24, 129-194)

Cherry, K. (2013). Erickson’s Stages of Psychosocial Development. Psychosocial Development in Young Adulthood, Middle age and Old age. Retrieved from .

UnboundMedicine. (2013). David’s drug guide. Retrieved from

United States Department of Agriculture. (2011). What’s on your plate? Retrieved from

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