UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Caitlin Darby |
|Patient Assessment Tool . |Assignment Date: October 7, 2013 |
| ( 1 PATIENT INFORMATION |Agency: Florida Hospital Tampa |
|Patient Initials: M.J. |Age: 55 |Admission Date: September 23, 2013 |
|Gender: Male |Marital Status: Divorced |Primary Medical Diagnosis with ICD-10 code: |
|Primary Language: English |Unstable Angina: I20.0 |
|Level of Education: Associates Degree: Construction Management |Other Medical Diagnoses: (new on this admission) |
|Occupation (if retired, what from?): Disabled | |
|Number/ages children/siblings: 2 brothers: Ages 61 & 63 | |
|Children: 1 girl, 17 years old | |
|Served/Veteran: Yes, Army (1974-1976) |Code Status: Full Code |
|Living Arrangements: The patient lives alone in a one-story single family home. |Advanced Directives: The patient has an advanced directive |
| |If no, do they want to fill them out? |
| |Surgery Date: N/A Procedure: N/A |
|Culture/ Ethnicity /Nationality: Caucasian | |
|Religion: Episcopal |Type of Insurance: Medicaid |
|( 1 CHIEF COMPLAINT: “ I woke up at about 4:30am with a horrible sharp stabbing pain in my chest. I have had 5 previous heart attacks and was experiencing the |
|same type of pain I had during those. I was having trouble breathing and was very scared since I was home alone. I assumed I was having another heart attack since |
|my symptoms were very similar. I took an aspirin and 2 tums and drove myself to the ER.” |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
|The patient is a 55-year-old male who complains of severe chest pain and shortness of breath. He stated that he has been having these symptoms since the morning of|
|September 23, 2013. The patient stated that his chest pain and shortness of breath remained constant since their onset and they interfered with his daily routine. |
|The symptoms made him anxious and nervous since they were similar to the symptoms he experienced during his 5 previous myocardial infarctions. The patient |
|described his symptoms as burning, sharp, aching and as though he couldn’t catch his breath. The patient stated that his symptoms were worse upon exertion and he |
|would become winded if excess energy were required. The patient tried aspirin and tums to relieve his chest pain but they were unsuccessful. He stated that nothing|
|relieved or lessened his symptoms except for lying on his side and that his pain didn’t radiate anywhere else in his body. When asked to describe the severity of |
|his symptoms on a scale of 0-10 he reported the intensity of a 8/10. The patient was admitted to CCU on September 23, 2013 where he underwent treatment for |
|unstable angina, including a cardiac catherization, chest x-rays, EKG’s, telemetry monitoring, and oxygen therapy. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
|1995 |Coronary Artery Bypass Graft |
|1975 |Malignant tumor removed from the patients right bicep |
|1983 |Benign tumor removed from the patient’s patella |
|2010 |Right femoral bypass |
|2011 |Bilateral femoral bypass |
|05/2012 |Insertion of pacemaker |
|05/2013 |Placement of 5 stents |
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|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
| |The patient does not recall the date of onset for any family members. |
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|( 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) (2012) | | |
|Adult Tetanus (Date) (2012) | | |
|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 |No Known Allergies | |
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|Other (food, tape, latex, dye, |No Known 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) |
|Unstable Angina: Unstable angina is described as a syndrome of falling between stable angina and acute myocardial infarction. A thrombus forms in an area where an |
|artery of the heart has narrowed (stenosis) but it is then destroyed or partially destroyed by an antithrombotic mechanism within the heart. Symptoms worsen and |
|the patient presents with the development of new onset exercise angina, angina present at rest for more than 20 minutes, or symptoms that have accelerated in |
|frequency, duration or intensity. Risk factors for unstable angina include age, hypertension, tobacco use, diabetes, dyslipidemia, coronary artery disease, |
|sedentary lifestyle, and overweight/obesity. Diagnostic tests include: 12-lead EKG and serum biomarkers. Treatment includes: Aspirin, nitroglycerin sublingual, |
|supplemental oxygen, morphine sulfate and an oral beta-blocker. Patients with unstable angina/NSTEMI have a lower in hospital mortality rate than those with a |
|STEMI but have a similar or worse long-term outcome. |
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|Reference: Osborne, K.S., Wraa, C.E. &Watson, A.B. (2010). Medical –Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson. |
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( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name Glyburide |Concentration (mg/ml) 5mg/TAB |Dosage Amount (mg) 5mg |
|Route PO |Frequency BID |
|Pharmaceutical class Sulfanylureas |Home Hospital or Both |
|Indication Control of blood sugar in type 2 diabetes mellitus when diet therapy fails |
|Side effects/Nursing considerations Dizziness, drowsiness, headache, weakness, constipation, cramps, nausea, vomiting, photosensitivity, rashes, hypoglycemia and |
|hyponatremia |
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|Name Metformin |Concentration 500mg/TAB |Dosage Amount 500mg |
|Route PO |Frequency BID |
|Pharmaceutical class Biguanides |Home Hospital or Both |
|Indication Management of type 2 diabetes mellitus, may be used with diet |
|Side effects/Nursing considerations Abdominal bloating, diarrhea, nausea, vomiting, hypoglycemia and lactic acidosis |
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|Name Atorvastatin |Concentration 20mg/TAB |Dosage Amount 20mg |
|Route PO |Frequency 1 tablet at night |
|Pharmaceutical class Hmg COA reductase inhibitors |Home Hospital or Both |
|Indication Adjunctive management of hypercholesterolemia and mixed dyslipidemia |
|Side effects/Nursing considerations Amnesia, confusion, dizziness, insomnia, memory loss, rhinitis, bronchitis, chest pain, peripheral edema, abdominal cramps and|
|constipation |
|Name Lisinopril |Concentration 20mg/TAB |Dosage Amount 20mg |
|Route PO |Frequency Daily |
|Pharmaceutical class Ace Inhibitors |Home Hospital or Both |
|Indication Management of heart failure |
|Side effects/Nursing considerations Dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, erectile |
|dysfunction and rashes |
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|Name Gabapentin |Concentration 300mg/CAP |Dosage Amount 300mg |
|Route PO |Frequency TID |
|Pharmaceutical class Anticonvulsants |Home Hospital or Both |
|Indication Partial seizures |
|Side effects/Nursing considerations Suicidal thoughts, confusion, depression, drowsiness, sedation, anxiety, abnormal vision, hypertension, weight gain, anorexia|
|and flatulence |
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|Name Carvedilol |Concentration 6.25mg/TAB |Dosage Amount 6.25mg |
|Route PO |Frequency BID |
|Pharmaceutical class Beta blockers |Home Hospital or Both |
|Indication Hypertension and heart failure |
|Side effects/Nursing considerations Dizziness, fatigue, weakness, anxiety, blurred vision, dry eyes, bronchospasm, wheezing, bradycardia, heart failure, |
|pulmonary edema and diarrhea |
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|Name Aspirin |Concentration 81mg/TAB |Dosage Amount 81mg |
|Route PO |Frequency Daily |
|Pharmaceutical class Salicylates |Home Hospital or Both |
|Indication Prophylaxis of transient ischemic attacks and MI |
|Side effects/Nursing considerations Tinnitus, GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anemia, hemolysis, and rash |
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|Name Clopidogrel |Concentration 75mg/TAB |Dosage Amount 75mg |
|Route PO |Frequency Daily |
|Pharmaceutical class Platelet aggregation inhibitors |Home Hospital or Both |
|Indication Reduction of atherosclerotic events |
|Side effects/Nursing considerations Depression, dizziness, fatigue, headache, epistaxis, cough, dyspnea, chest pain, edema, hypertension, GI bleeding abdominal |
|pain, pruritis, gastritis, bleeding, and back pain |
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|Name Enoxaparin |Concentration 40mg/INJ |Dosage Amount 40mg |
|Route Subcutaneous |Frequency Daily |
|Pharmaceutical class Antithrombolytics/ low molecular weight heparin |Home Hospital or Both |
|Indication Prevention of venous thromboembolism (VTE) and/or pulmonary embolism (PE) in surgical or medical patients |
|Side effects/Nursing considerations Dizziness, headache, insomnia, edema, constipation, urinary retention, rash, hyperkalemia, bleeding, anemia, nausea and |
|vomiting |
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|Name Fenofibrate |Concentration 145mg/TAB |Dosage Amount 145mg |
|Route PO |Frequency Daily |
|Pharmaceutical class Fibric acid derivatives |Home Hospital or Both |
|Indication With dietary therapy to decrease LDL cholesterol, total cholesterol and triglycerides |
|Side effects/Nursing considerations Fatigue, weakness, headache, pulmonary embolism, DVT, rash, uticaria, rhabdomyolysis, and pancreatitis |
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|Name Nitroglycerin Topical |Concentration 1gram/TOPICAL |Dosage Amount 1 gram |
|Route Transdermal |Frequency Q6H |
|Pharmaceutical class Nitrates |Home Hospital or Both |
|Indication Acute and long term prophylactic management of angina pectoris |
|Side effects/Nursing considerations Dizziness, headache, blurred vision, hypotension, tachycardia, syncope, abdominal pain, nausea, vomiting and contact |
|dermatitis |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Con-carb/Heart Healthy Diet |Analysis of home diet (Compare to “My Plate” and |
|Diet pt follows at home? |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
|Breakfast: The patient typically has eggs, bacon, white toast with grape jelly, |For a male 55 years old, the minimum amount per day of each group of food is as |
|hash browns, and a glass of whole milk for breakfast. He will sometimes have a |follows: |
|coke instead of milk for breakfast. |Fruit: 1 ½ cups |
| |Vegetables: 2 cups |
| |Grains: 5 ounces |
| |Protein: 5 ounces |
| |Dairy: 3 cups |
| |Oils: 5 teaspoons |
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|Lunch: The patient typically choses to skip lunch. He stated that he usually | |
|wakes up around 10:00-10:30am and will cook breakfast so by the time he eats it | |
|is more like brunch. He usually will have a diet pepsi around this time for | |
|caffeine. | |
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|Dinner: The patient typically cooks a sirloin steak with A1 sauce, baked potato | |
|with butter, sour cream, bacon, salt and pepper, asparagus and a glass of milk or| |
|water. | |
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|Snacks: The patient typically will have an orange, banana or grapes as his snack | |
|of choice. | |
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|Liquids (include alcohol): The patient does not consume alcohol. His drinks of | |
|choice are whole milk, water or diet pepsi. | |
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|[pic] |Overall this patient is eating a fairly balanced diet for his age. From the |
| |24-hour recall it appears that his favorite thing to drink is milk so I assume he|
| |is meeting the recommended amount per day. I would encourage the patient to try |
| |and switch to skim or 1% milk instead of whole milk. The patient should also try |
| |and eat turkey bacon rather than regular bacon as it is less fattening and more |
| |“heart healthy.” I would also encourage the patient to incorporate more whole |
| |grains into his diet. Instead of having white toast for breakfast he could try |
| |switching to whole wheat or whole grain toast to meet the recommended daily |
| |amount for his age. Fruit is also an important part of the patient’s diet that is|
| |lacking. He could occasionally incorporate a fruit cup or sliced fruit alongside |
| |his meals. The patient should also try and drink more water throughout the day. |
| |It is important for the patient to consume the recommended amount per day for his|
| |age. |
|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? Patient stated: “Before my daughter left for college at Emory University in Atlanta, GA I mainly relied on her to help take care of|
|me when I was sick. Now that I am at home alone I don’t have anyone to help me so I tend to rely on myself.” |
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|How do you generally cope with stress? or What do you do when you are upset? Patient stated: “ When I am stressed or upset I like to go camping. Other times I will|
|go fishing in the gulf. These two things really seem to lift my mood and calm my nerves. If I can’t do either one of these things I like to watch the news.” |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) Patient stated: “I really haven’t experienced any |
|recent difficulties other than my recent diagnosis and hospitalization. I sometimes get a little sad knowing that I let myself get to this point by failing to |
|change my lifestyle and care for my body and now there is no reversing it.” |
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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? Patient stated: “No” |
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|Have you ever been talked down to? Patient stated: “No” |
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|Have you ever been hit punched or slapped? Patient stated: “No” |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? Patient stated: “No” |
|If yes, have you sought help for this? N/A |
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|Are you currently in a safe relationship? Patient stated: “I am currently not in a relationship.” |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |
|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |
|patient’s age group: |
|Generativity vs. Stagnation |
|Middle adulthood (ages 40-65) typically involves work and parenthood for most individuals. During this stage adults often establish their careers, settle down in a|
|relationship, create a family and develop a sense belonging. Also, adults will try and give back to society by raising their children, being productive citizens at|
|work, and becoming active and involved in community events/organizations. If a person accomplishes these objectives and is successful they are classified under |
|generativity and develop the virtue of care. If a person fails to achieve these milestones they often become stagnant and unproductive in society. |
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|Reference: |
|Berk, L.E., (2012). Infants, children, and adolescents (7th ed.). Boston: Allyn & Bacon. |
|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|My patient is considered to be in the generativity vs. stagnation developmental stage because he is 55 years old, which falls in between the ages of 40-65. My |
|patient was in a great mood and was engaged with me in conversation throughout the course of asking him questions. He was quite pleasant to interact with and had |
|many stories to tell about his daughter and career. Although his marriage wasn’t successful, he didn’t let that stop him from enjoying the journey of life. He |
|gained custody of his daughter after his divorce and raised her in Tampa, FL. He just recently sent her off to college at Emory University in Atlanta to study |
|nursing. He spoke often about the many trips that he and his daughter took while growing up. He also mentioned his love for fishing in the gulf, going camping, |
|rocking on the porch and watching the news. The patient also spoke about how close he was with his two brothers and about their wonderful childhood and parents. He|
|established his career upon graduating with an AA degree in construction management. He was contracted to build all of the Walgreens in Tampa, FL. He was recently |
|put on disability due to his heart condition but he didn’t let this affect his life or happiness. He seemed to live a very happy, cheerful and outgoing life and |
|will continue to live this way despite his health problems. I believe he exhibits the characteristics of generativity vs. stagnation because he has been an |
|involved citizen, formed relationships, established a career, and created a family and seems to be very happy with the way his life has turned out thus far. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |
|I believe that being hospitalized and in ICU for unstable angina as well as his having a cardiac history has definitely had an impact on my patient’s developmental|
|stage of life. In the past 10 years this patient has been diagnosed with coronary artery disease, peripheral vascular disease and congestive heart failure. He also|
|had 6 myocardial infarctions, 5 stents placed, a bilateral femoral bypass, coronary artery bypass graft, and a pacemaker placed all requiring hospitalization. |
|Prior to being diagnosed with these conditions the patient lived a very active and healthy life with his daughter. Once diagnosed with cardiac problems he had to |
|modify his day-to-day activities and was eventually put on disability requiring him to leave the job he loved most, construction. These major changes in his life |
|had to be emotional and overwhelming especially at the young age of 45. He stated that he sometimes experiences anxiety due to the rapid decline in his health |
|status as well as being told that there is nothing else the physicians can do to help him because he failed to modify his diet and lifestyle. Being in the hospital|
|as well as being diagnosed with the conditions listed above can take a toll on your emotions, sense of well-being and your body when you are used to living an |
|active lifestyle with no limitations or set-backs. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” |
|Patient stated: “I believe that my illness is partly caused by genetics since both my brothers and parents had these same problems I have. I also contribute not |
|modifying my lifestyle (diet, exercise, medication adherence) like I was advised to as potentially causing my illness.” |
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|What does your illness mean to you? |
|Patient stated: “My illness means that I am going to have to change my lifestyle because I am not physically capable of doing the things I used to do so basically |
|it means I am getting old.” |
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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |
|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |
|usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record” |
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|Have you ever been sexually active? Patient stated: “Yes” |
|Do you prefer women, men or both genders? Patient stated: “Women” |
|Are you aware of ever having a sexually transmitted infection? Patient stated: “No” |
|Have you or a partner ever had an abnormal pap smear? Patient stated: “No” |
|Have you or your partner received the Gardasil (HPV) vaccination? Patient stated: “No” |
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|Are you currently sexually active? Patient stated: “No” When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or |
|an unintended pregnancy? Patient stated: “Condoms” |
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|How long have you been with your current partner? Patient stated: “I currently do not have a partner” |
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|Have any medical or surgical conditions changed your ability to have sexual activity? Patient stated: “Yes, last year when I had my pacemaker placed” |
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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? Patient stated: “No” |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient stated: “ I go to church every Sunday (Episcopal) with my daughter. I got right with God when I got really sick last year and I pray for healing often but I know if there is a Heaven then I am definitely going there because I believe in my savior, Jesus Christ. “ _____________________________________________________________________________________________________
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Do your religious beliefs influence your current condition?
Patient stated: “ I do. I am ready and I have a sense of peace about my condition that only God can give me. I know if I die today that I am going up and not down. I am saved. “ ______________________________________________________________________________________________________
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|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |
| If so, what? |How much?(specify daily amount) |For how many years? 30X years |
|Cigarettes |2 packs per day |(age 15 thru 2008 ) |
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| | |If applicable, when did the patient quit? The|
| | |patient quit in August 2008 using Chantix |
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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? Yes; successfully |
|Patient stated: “No one besides me” | |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |
| What? |How much? (give specific volume) |For how many years? 21 years |
|Wild Turkey Honey shots and Beer |15-20 drinks per day |(age 18 thru 1997 ) |
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| If applicable, when did the patient quit? Patient stated: | | |
|“I quit 17 years ago” | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |
| If so, what? N/A |
| |How much? N/A |For how many years? N?A |
| | |(age N/A thru N/A ) |
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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? N/A | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
|Patient stated: “None that I am aware of” |
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( 10 Review of Systems
|General Constitution |Gastrointestinal |Immunologic |
| Recent weight loss or gain | Nausea, vomiting, or diarrhea | Chills with severe shaking |
|Integumentary | Constipation Irritable Bowel | Night sweats |
| Changes in appearance of skin | GERD Cholecystitis | Fever |
| Problems with nails | Indigestion Gastritis / Ulcers | HIV or AIDS |
| Dandruff | Hemorrhoids Blood in the stool | Lupus |
| Psoriasis | Yellow jaundice Hepatitis | Rheumatoid Arthritis |
| Hives or rashes | Pancreatitis | Sarcoidosis |
| Skin infections | Colitis | Tumor |
| Use of sunscreen SPF: | Diverticulitis | Life threatening allergic reaction |
|Bathing routine: 2x per day |Appendicitis | Enlarged lymph nodes |
|Other: | Abdominal Abscess |Other: |
| | Last colonoscopy? (Never had one) | |
|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: O+ |
| Post-nasal drip |Normal frequency of urination: 7 x/day |Other: |
| Oral/pharyngeal infection | Bladder or kidney infections | |
| Dental problems (upper dentures) | |Metabolic/Endocrine |
| Routine brushing of teeth 1 x/day | | Diabetes Type: 2 |
| Routine dentist visits 1x/year | | Hypothyroid /Hyperthyroid |
|Vision screening | | Intolerance to hot or cold |
|Other: | | Osteoporosis |
| | |Other: |
|Pulmonary | | |
| Difficulty Breathing | |Central Nervous System |
| Cough - dry or productive |Women Only | CVA |
| Asthma | Infection of the female genitalia | Dizziness |
| Bronchitis | Monthly self breast exam | Severe Headaches |
| Emphysema | Frequency of pap/pelvic exam | Migraines |
| Pneumonia | Date of last gyn exam? | Seizures |
| Tuberculosis | menstrual cycle regular irregular | Ticks or Tremors |
| Environmental allergies | menarche age? | Encephalitis |
|last CXR? (9-24-13) | 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 |
| Hyperlipidemia | Frequency of prostate exam? | Schizophrenia |
| Chest pain / Angina | Date of last prostate exam?(03/2013) | Anxiety |
|Myocardial Infarction | BPH | Bipolar |
| CAD/PVD |Urinary Retention |Other: |
|CHF |Musculoskeletal | |
|Murmur | Injuries or Fractures |Childhood Diseases |
| Thrombus | Weakness | Measles |
|Rheumatic Fever | Pain | Mumps |
| Myocarditis | Gout | Polio |
| Arrhythmias | Osteomyelitis | Scarlet Fever |
| Last EKG screening, when? (9-24-13) |Arthritis | Chicken Pox |
|Other: |Other: |Other: |
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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |
|Patient stated: “No” |
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|Any other questions or comments that your patient would like you to know? |
|Patient stated: “No” |
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|±10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes) |
|General Survey: A&Ox3 |Height: 6’1” |Weight: 262.2 BMI: 34.22 |Pain: (include rating & location) |
| | | | |
| | | |8/10: chest pain |
| |Pulse: 92 |Blood | |
| | |Pressure: 133/90 | |
| | |(include location) | |
|Temperature: (route taken?) |Respirations: 35 | | |
|97.4: oral | | | |
| |SpO2 100 |Is the patient on Room Air or O2: O2: 2L nasal cannula |
|Overall Appearance: [Dress/grooming/physical handicaps/eye contact] |
| clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
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|Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other] |
| awake, calm, relaxed, interacts well with others, judgment intact |
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|Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] |
| clear, crisp diction |
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|Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat |
| apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud |
|Other: |
|Integumentary | |
| Skin is warm, dry, and intact | |
| Skin turgor elastic | |
| No rashes, lesions, or deformities | |
| Nails without clubbing | |
| Capillary refill < 3 seconds | |
| Hair evenly distributed, clean, without vermin | |
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| Peripheral IV site Type: Peripheral Line #20 gauge Location: Right Forearm Date inserted: 9-23-13 |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? 0.9% Sodium Chloride 1000 ml (100ml/hr) |
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|The patient was given a 500ml fluid bolus to try and increase urine output |
| Peripheral IV site Type: Location: Date inserted: |
| no redness, edema, or discharge |
| Fluids infusing? no yes - what? |
| Central access device Type: Location: Date inserted: |
|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- 6 inches & left ear- 6 inches |
| Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|Dentition: Upper set of dentures; Lower teeth white and intact |
|Comments: |
| |
|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 |* No sputum production |
| |D – Diminished | |
| |S – Stridor | |
| |Ab - Absent | |
| | | |
| | | |
|Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th intercostal space mid-clavicular 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: Didn’t assess Carotid: Didn’t assess Brachial: Didn’t assess Radial: +3 Femoral: Didn’t assess |
|Popliteal: Didn’t assess DP: +2 PT: +3 |
|No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ] |
|Location of edema: Right lower extremity 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: Pale 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 |
|Last BM: (date 09 / 22 / 2013 ) Formed Semi-formed Unformed Soft Hard Liquid Watery |
|Patient stated: “My last bowel movement was the day before I was admitted and it was formed and a medium brown color” |
|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 _5______ RUE __5_____ LUE ___5____ RLE & ___5____ in LLE |
|[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance] |
|vertebral column without kyphosis or scoliosis |
|Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or 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 (didn’t assess) |
|Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride |
|(Didn’t assess) 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 |
| |
| |
| |
| |
|±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: 258 |
|Glucose: 293 |
|Glucose: 222 |
|Glucose: 217 |
|Normal Range: 65-99 mg/dL |
| |
| |
| |
|HDL: 25 |
|Normal Range: 60 mg/dL |
| |
|Triglycerides: 470 |
|Normal Range: Below 150 mg/dL |
|(09-23-13) |
|(09-23-13) |
|(09-23-13) |
|(09-24-13) |
| |
| |
| |
| |
| |
|(09-24-13) |
| |
| |
|(09-24-13) |
|The patient’s blood sugar has remained in the 200 range since admission to the emergency room. He admitted that he neglects to check or manage his blood sugar levels|
|at home. |
| |
|The patient’s HDL cholesterol level was low while his triglyceride levels were extremely elevated. He admitted that he is prescribed atorvastatin to manage his |
|cholesterol levels but stopped taking his medication back in August and has never modified his diet. |
|The patient fails to maintain proper glucose levels in the body by neglecting to check and cover his insulin needs. |
| |
|The patient is unwilling to manage his cholesterol levels. He fails to take his medication and modify his lifestyle and diet. |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |
|frequency if applicable.) |
|Diet: Con-carb (60 g carb/meal), Heart Healthy (Low sodium, fat and cholesterol) (9-23-13) |
|Vital Signs: Temperature (97.4), Blood pressure (133/90), Pulse (92), Respirations (35), O2 saturation (100%) |
|Activity: Bedrest then ambulate with assistance ordered (9-24-13) |
|Accu-checks: Q4H (9-23-13) |
|Oxygen Therapy: 2L nasal cannula (9-23-13) |
|Continuous Telemetry Monitoring: (9-23-13) |
|Continuous Pulse Oximetry Reading: (9-23-13) |
|Chest x-ray: No acute abnormality noted (9-23-13) |
|EKG: Normal sinus rhythm with occasional PVC’s (9-23-13) |
|Cardiac catherization: Subacute MI. Total occlusion of saphenous vein graft to right coronary artery. Failed percutaneous intervention because of the inability to |
|cross lesion of proximal saphenous vein graft to right coronary artery. The patients ejection fraction remains between 25-30% (9-23-13) |
|SCD’s/TEDS: Q8H (9-23-13) |
|Pacemaker interrogation: (9-24-13) |
| |
|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
| |
|Acute pain secondary to unstable angina a.e.b. patient report of pain of an 8/10 on the pain scale and observed evidence of pain (facial grimacing) |
| |
|Ineffective tissue perfusion r/t deficient knowledge of aggravating factors and hypertension a.e.b. diminished peripheral pulses |
| |
|Risk of falls secondary to vascular disease and antihypertensive agents a.e.b. patient report of weakness and instability when getting out of bed |
| |
|Activity intolerance r/t immobility and generalized weakness a.e.b.exertional discomfort or dyspnea (verbalizes no desire and/or lack of interest in activity |
| |
|Anxiety r/t threat of death and change in health status a.e.b. patient report of concerns due to change in life events |
| |
| |
± 15 CARE PLAN
Nursing Diagnosis: Activity intolerance r/t bedrest a.e.b.exertional discomfort or dyspnea (verbalizes no desire and/or lack of interest in activity
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |
| | |Provide References | |
|Short-term | | | |
| | | | |
|The patient will participate in physical activity |1. Monitor vitals before and after activity, noting |1. This can be caused by a temporary insufficiency of|1. The goal was not met. The patient was unwilling to|
|with appropriate changes in heart rate, blood |any abnormal changes |blood supply so we need to monitor for changes in |get out of bed due to getting winded and feeling |
|pressure and respirations by the end of shift. |2. Assess for pain before activity |cardiovascular status. |weak. |
| |3. Obtain any necessary assistive devices or |2. Pain restricts the client from achieving a maximal|2. The goal was partially met. I assessed his pain |
| |equipment needed before assisting in ambulation |activity level and movement often exacerbates pain. |level (8/10) before anticipated transfer from bed to |
| | |3. Assistive devices can increase mobility by helping|chair but the patient refused to do this activity. |
| | |the client overcome limitations. |3. The goal was not met. The patient refused to use |
| | | |any assistive devices or transfer from the bed to the|
| | | |chair. |
|Long-term | | | |
| | | | |
|The patient will demonstrate increased participation |1. Evaluate medications the client is taking to see |1. Medications such as beta-blockers, lipid-lowering |1. The goal was met. The patient is taking a |
|and tolerance to activity by discharge. |if they could be causing activity intolerance. |agents and antihypertensive can result in decreased |combination of all of these medications, which is |
| |2. Assess nutritional needs associated with activity |functioning. |contributing to his weakness, dyspnea and activity |
| |intolerance. |2. The decline in body mass with physical weakness |intolerance. |
| |3. Provide emotional support and encouragement to the|inhibits mobility, increasing risk for deep vein |2. The goal was met. The patient is eating an |
| |client to gradually increase activity. |thrombosis and pressure ulcers. |unbalanced diet contributing to his decline in |
| |4. Encourage activity and self-care gradually if |3. Fear of breathlessness, pain, or falling may |health. Dietary was consulted to discuss appropriate |
| |tolerated. Provide assistance as needed. |decrease the patient’s willingness to increase |meals/food for the client’s cardiac conditions. |
| | |activity. |3. The goal was met. I stayed with the patient for |
| | |4. Progress activity increases gradually to prevent |about 15 minutes and talked about the importance of |
| | |sudden cardiac work, provide only limited assistance |gradually increasing his activity level with |
| | |needs will encourage independence in their daily |assistance to improve his health status. |
| | |routines. |4. The goal was partially met. I encouraged the |
| | | |patient to transfer himself to the chair with my |
| | | |assistance but he refused 2x during my shift. |
| | | | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|Ensure that when to notify health care provider is clear |
|Schedule follow up appointments with health care providers and encourage follow up care |
|Disease process/prognosis understood |
|Assess availability and knowledge with treatment regime |
|Assess discharge placement needs: home, rehabilitation or extended facility |
|Encourage increase in independent activity as appropriate |
|Encourage the participation in support groups |
|Assess the need for psychological counseling |
|Maintain a diet that is balanced limiting sodium, fat and cholesterol |
|Observe for weight loss and/or loss of appetite |
|Assess chest pain level and report any increase in chest pain |
|Instruct about the timing and frequency of analgesic meds |
|Assess home environment for safety |
|Lifestyle changes identified/initiated to prevent recurrence |
|Instruct the patient to take medications as prescribed and make sure they understand the side and adverse effects as well as when to call the provider |
|Have patient discuss any questions or concerns before discharge |
± 15 CARE PLAN
Nursing Diagnosis: Risk of falls secondary to vascular disease and antihypertensive agents a.e.b. patient report of weakness and instability when getting out of bed
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |
| | |Provide References | |
|Short-term | | | |
| | | | |
|1. Client will identify factors that may cause or |1. Identify factors that may cause or contribute to |1. Increases the client’s awareness. |1. The goal was met. We discussed factors that can |
|contribute to injury from a fall. |injury from a fall. | |contribute to a fall such as quick movements, clutter|
| | | |on the floor, unfamiliar environment, etc. |
| | | | |
|2. Client will remain free of falls each shift. |2. Routinely assist the client in toileting on his |2. Keep path to the bathroom clear and leave the door| |
| |own schedule. |open. Falls are often linked to the need to eliminate|2. The goal was met. I organized the cords on the |
| | |in a hurry. |floor and cleared the floor of fall hazards. |
| | | | |
| | | | |
|Long-term | | | |
| | | | |
|3. Client will not experience any falls during their |3. Orient client to environment. Assess their ability|3. These measures will help the client cope with an |3. The goal was met. The client and I thoroughly went|
|hospital stay. |to use the call bell, side rails and bed controls. |unfamiliar environment. |over how to work the bed, how to use the call light |
| | | |and the importance of leaving at least 2 side rails |
| | | |up. |
| | | | |
|4. Client will make the necessary physical changes in|4. Make changes in the client’s environment that may |4. Increases the client’s awareness. |4. The goal was met. The client stated that he and |
|environment to ensure increased safety within first |cause or contribute to a fall related injury. | |his housekeeper would organize and clean up clutter |
|week of returning home. | | |around his house when he was discharged to make sure |
| | | |his home environment was safe to prevent falls. |
| | | | |
| | | | |
|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
| |
|Consider the following needs: |
|Ensure that when to notify health care provider is clear |
|Schedule follow up appointments with health care providers and encourage follow up care |
|Disease process/prognosis understood |
|Assess availability and knowledge with treatment regime |
|Assess discharge placement needs: home, rehabilitation or extended facility |
|Encourage increase in independent activity as appropriate |
|Encourage the participation in support groups |
|Assess the need for psychological counseling |
|Maintain a diet that is balanced limiting sodium, fat and cholesterol |
|Observe for weight loss and/or loss of appetite |
|Assess chest pain level and report any increase in chest pain |
|Instruct about the timing and frequency of analgesic meds |
|Assess home environment for safety |
|Lifestyle changes identified/initiated to prevent recurrence |
|Instruct the patient to take medications as prescribed and make sure they understand the side and adverse effects as well as when to call the provider |
|Have patient discuss any questions or concerns before discharge |
± 15 CARE PLAN
Nursing Diagnosis: Ineffective tissue perfusion r/t deficient knowledge of aggravating factors and hypertension a.e.b. diminished peripheral pulses
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Interventions on Day care is Provided |
| | |Provide References | |
|Short-term | | | |
| | | | |
|The client will demonstrate adequate tissue perfusion|1. Monitor peripheral pulses. If there is new onset |1. These are symptoms of arterial obstruction that |1. The goal was met. The client’s peripheral pulses |
|as evidence by blood pressure and pulse rate and |of loss of pulses with bluish, purple or black areas |can result in loss of a limb if not immediately |were palpated every 2 hours. They remained weak |
|rhythm within normal parameters for the client; |and extreme pain, notify the physician immediately. |reversed. |throughout my shift. |
|palpable peripheral pulses, warm/dry skin and ability|2. Keep the client warm and have the client wear |2. Keep extremities warm to maintain vasodilation and|2. The goal was met. The client wore his fall |
|to tolerate activity without dyspnea, syncope or |socks and shoes or slippers while mobile. Do not |blood supply. Heat application can easily damage |prevention socks throughout the day. When |
|chest pain and increased urine output by end of |apply heat. |ischemic tissue. |transferring to a new unit or ambulating he had |
|shift. |3. Do not elevate the legs above the level of the |3. With arterial insufficiency, leg elevation |slippers available. |
| |heart. |decreases arterial blood supply to the legs. |3. The goal was met. The client’s legs were never |
| |4. Note skin color and feel the temperature of the |4. Skin pallor or mottling, cool or cold skin |elevated above his heart during my shift. |
| |skin. |temperature or an absent pulse can signal arterial |4. The goal was met. The client’s skin color and |
| |5. Check capillary refill every 2 hours. |obstruction, which is an emergency that requires |temperature were observed every 2 hours. They |
| |6. Note skin texture and the presence of hair, ulcers|immediate intervention. Brownish discoloration of the|remained pink, warm and dry. Pitting edema was still |
| |or gangrenous areas on the legs or feet. |skin indicates chronic venous insufficiency. |present on the right lower extremities. |
| |7. Assess for pain in the extremities, noting |5. Nail beds usually return to a pinkish color within|5. The goal was met. The patient’s capillary refill |
| |severity, quality, timing and |2-3 seconds after nail bed compression. |remained < 3 seconds. |
| |exacerbating/alleviating factors. Differentiate |6. Thin, shiny, dry skin with hair loss; brittle |6. The goal was met. The patient’s skin texture was |
| |venous from arterial. |nails, and gangrene or ulcerations on toes and |observed and hair was present. No ulcers or |
| |8. Assess client’s nutritional status, paying close |anterior surfaces of the feet are seen in clients |gangrenous areas were present during my shift. |
| |attention to obesity, hyperlipidimia, and |with arterial insufficiency. |7. The goal was met. The patient described a |
| |malnutrition. Refer to a dietician if appropriate. |7. In clients with venous insufficiency. The pain |tingling/numbness in his lower extremities that he |
| |9. Observe for signs of DVT, including pain, |lesions with elevation of the legs and exercise. In |associated with his diabetes. He rated it as a 5/10 |
| |tenderness, or swelling in the calf and thigh, and |clients with arterial insufficieny, The pain |and stated it was constant. |
| |redness in the involved extremity |increases with elevation of the legs and exercise. |8. The goal was met. The client is obese and his |
| |10. Measure urine output hourly. |Some clients have both arterial and venous insuff. |triglyceride levels were quite elevated. He stated |
| |11. Perform toe-up and point-flex exercises. |Arterial is associated with pain when walking that is|that he doesn’t maintain a diet sufficient for his |
| | |relieved by rest. Clients with severe arterial |cardiac condition and diabetes. A dietary consult was|
| | |disease have foot pain while at rest |made for the patient. |
| | |8. Malnutrition contributes to anemia, which further |9. The goal was met. The patient had no signs of a |
| | |compounds the lack of oxygenation to tissues |DVT during my shift. |
| | |9. Thrombosis with clot formation usually first |10. The goal was met. The patient used the urinal |
| | |detected as swelling of the involved leg and then as |which made is easy to measure urine output. Initially|
| | |pain. Leg measurement discrepancies of more than 2 |he was not putting out sufficient urine so a 500ml |
| | |cm warrant further investigation |fluid bolus was given during night shift. 1750ccs |
| | |10. An output below 30ml/hr may indicate deficient |were measured in a 24-hour period. |
| | |fluid vol., which can result decreased oxygen |11. The goal was met. The patient was taught how to |
| | |delivery and organ system failure |perform these exercises and stated that it made his |
| | |11. Exercise helps to increase venous return, build |lower extremity pain more bearable. |
| | |up collateral circulation, and strengthen the calf | |
| | |muscle pumps | |
|Long-term | | | |
| | | | |
|Client will verbalize knowledge of their treatment |1. Pay meticulous attention to foot care. Inform the |1. Ischemic feet are very vulnerable to injury; |1. The goal was met. I observed his feet every 2 |
|regimen, including appropriate exercise and |client to see a podiatrist if they have a foot or |meticulous foot care prevents further injury |hours during my shift. The patient stated that he had|
|medications, their actions and possible side effects |nail abnormality |2. Exercise helps to increase venous return, build up|already been informed to check his feet regularly due|
| |2. Teach the patient toe-up and point-flex exercises.|collateral circulation, and strengthen the calf |to his diabetes. |
| | |muscle pumps. |2. The goal was met. The patient was taught how to |
| |3. Teach the patient how to monitor their peripheral |3. These are symptoms of arterial obstruction that |perform these exercises and stated he would do them |
| |pulses. If there is new onset of loss of pulses with |can result in loss of a limb if not immediately |at home because they made his lower extremity pain |
| |bluish, purple or black areas and extreme pain, |reversed |more bearable. |
| |notify the physician immediately. |4. Thrombosis with clot formation usually first |3. The goal was met. The patient demonstrated |
| |4. Teach the patient the signs of a DVT: pain, |detected as swelling of the involved leg and then as |palpation of his peripheral pulses. We showed him how|
| |tenderness, or swelling in the calf and thigh, and |pain. Leg measurement discrepancies of more than 2 |to find them and then marked X’s on the location so |
| |redness in the involved extremity. Instruct the |cm warrant further investigation |he could find them easier. |
| |patient to monitor for these signs daily. | |4. The goal was met. I discussed the symptoms of a |
| | | |DVT with the patient and he verbalized understanding.|
| | | | |
|± DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
| |
|Consider the following needs: |
|Ensure that when to notify health care provider is clear |
|Schedule follow up appointments with health care providers and encourage follow up care |
|Disease process/prognosis understood |
|Assess availability and knowledge with treatment regime |
|Assess discharge placement needs: home, rehabilitation or extended facility |
|Encourage increase in independent activity as appropriate |
|Encourage the participation in support groups |
|Assess the need for psychological counseling |
|Maintain a diet that is balanced limiting sodium, fat and cholesterol |
|Observe for weight loss and/or loss of appetite |
|Assess chest pain level and report any increase in chest pain |
|Instruct about the timing and frequency of analgesic meds |
|Assess home environment for safety |
|Lifestyle changes identified/initiated to prevent recurrence |
|Instruct the patient to take medications as prescribed and make sure they understand the side and adverse effects as well as when to call the provider |
|Have patient discuss any questions or concerns before discharge |
References
Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. St. Louis, MI: Mosby Elsevier.
Berk, L.E., (2012). Infants, children, and adolescents (7th ed.). Boston: Allyn & Bacon.
Osborne, K.S., Wraa, C.E. & Watson, A.B. (2010). Medical –Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson.
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