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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Vivarian Moulton

MSI & MSII PATIENT ASSESSMENT TOOL .

Assignment Date: 01/20/2015


Agency: SJH

1 PATIENT INFORMATION
Patient Initials: RI

Age: 37

Admission Date: 01/19/2015

Gender: Male

Marital Status: Engaged/ Single

Primary Medical Diagnosis: Unstable angina,


angina, atypical chest pain
Reason for admission: Chest pain

Primary Language: English


Level of Education: Trade School after high school completion
Occupation (if retired, what from?): Unemployed, he was a general
manager at an A/C company
Number/ages children/siblings: 7 children/ ages: 5-14/ 2 older
sisters

Served/Veteran:
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives with his fianc, 5 children and
his dog and cat. Patient can independently care for himself however
his fianc is there as a secondary caretaker if needed.
Culture/ Ethnicity /Nationality: Hispanic/ Puerto Rican
Religion: Not religious

Other Medical Diagnoses: (new on this admission)


No new diagnoses on this admission

Code Status: Full code


Advanced Directives: Patient has a will. I
explained what an advanced directive is and he
was not interested in filling one out.
If
no, doDate:
they want to fillProcedure:
them out?
Surgery
None
Type of Insurance: Medicaid

1 CHIEF COMPLAINT:
Patient states, I was having chest pain, tingling in fingers and jaw pain.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient came to the emergency room on 01/19/2015 after 5 hours of unrelieved, intermittent, nonexertional, anterior chest
pain that was a combination of crushing and sharp, achy. The chest pain was unrelieved by nitroglycerin, relieved on its
own. Patient is post bypass from infancy because of congenital stenosis, multiple ablations for arrhythmias and pacemaker
placement. Two blood tests revealed negative troponin and BNP of 67.8; chest x rays showed symmetrically expanded
with no markings of pneumothorax, consolidation and pleural fluid, the cardio mediastinal structure is within the larger
size of normal limits and an electrocardiogram (EKG/ECG) showed normal sinus rhythm with first degree AV block,
nonspecific ST and T wave abnormalities and PR interval abnormalities. An ultrasound was conducted on 01/20/2015 but
the results were unavailable. The patient was transferred to the telemetry floor on 01/19, placed on tele box 70, and is
being worked up to rule out myocardial infarction. Patient is being continued on aspirin, Coumadin, bisoprolol, and
mexiletine with Lipitor and lovenox added to increase the patients INR from 1.9 to 2.5-3.5. On 01/20 Lisinopril was
added to his treatment plan. Patient has a consult with his pediatric cardiologist for evaluation and is scheduled for a stress
test today.

University of South Florida College of Nursing Revision September 2014

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease

Father

62

Mother

58

Sister

38

Sister

41

Tumor

Stroke

Stomach Ulcers

Seizures

Kidney
Problems
Mental Health
Problems

Hypertension

(angina, MI, DVT etc.)

Heart Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Cause
of
Death
(if
applicable)

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

06/28/2012
09/09/2013
unknown

Environmental
Allergies

Operation or Illness
Congenital Heart Disease
Valvular Heart Disease
Bypass surgery
Aortic Valve Replacement
Diagnostic u/s of the heart, cardiac mapping, excision of tissue of heart: endovascular approach,
catheter based invasive electro physiologic testing
Paralyzed diaphragm- resolved
Automatic implantable cardioverter defibrillator placement
Gurd
Three ablations of the left ventricle due to arrhythmias

Alcoholism

Date
07/24/1977
07/24/1977
Infant
06/01/1993
06/28/2012

relationship
relationship
relationship

Comments: Include age of onset


The patients father developed stomach ulcers when the patient was younger (he does not remember when exactly) and his father was
diagnosed with prostate cancer in 2005 when the father was 57 years old. The patient is unsure when his mother was diagnosed with
arthritis.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? 2013, patient refused the vaccine
upon admission to hospitals
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

YES

University of South Florida College of Nursing Revision September 2014

NO

1 ALLERGIES
OR ADVERSE
REACTIONS
Medications

NAME of
Causative Agent
N/A

Type of Reaction (describe explicitly)


Patient has no allergies to food, medications, latex, and dye.

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)
Mechanics of disease: Angina is chest pain that occurs when the hearts demand for oxygen is not met, there is
insufficient blood flow to the heart. Stable angina is predictable and normally occurs when your heart is working hard and
needs more oxygen. With stable angina, the symptoms goes away with rest. Unstable angina is unexpected and does not
relieve with rest or nitroglycerin. Unstable angina (UA) is reoccurring and occurs with minimum or no exertion. It is an
indication that a heart attack is forthcoming. According to WebMD, Unstable angina presents with symptoms of a heart
attack to include squeezing or sharp chest pains, pain that radiates to extremities and/or back, nausea, anxiety, sweating,
shortness of breath, dizziness, unexplained fatigue (K Pai, 2014). Coronary artery disease (CAD) is the main cause of
unstable angina. CAD causes a buildup of plague in arteries which cause them to become narrow, restrict blood flow and
cause chest pain. Unstable angina is warning that if left untreated a heart attack may occur (Hall, 2012). UA can be
differentiated from non St elevation myocardial infarction by the absence of abnormal cardiac markers.
Risk factors: Risk factors for UA include elderly men and women, high blood pressure, tobacco use, diabetes,
dyslipidemia, smoking, family history of early coronary artery disease (CAD), sedentary lifestyle, overweight/Obesity,
NSAIDs, lack of exercise, and stress (Hall, 2012).
Diagnose: UA can be diagnosed with blood tests to check for cardiac enzymes which reveal heart damage; an ECG to
monitor heartbeats and irregularities that may indicate reduced blood flow; echocardiography for images of your heart;
stress tests to detect angina; coronary angiography uses x rays to study arteries for any blockages and narrowing; cardiac
catheterization and fasting lipid profile (Joffe, 2012).
Treatment: Treatment for UA is to prevent heart attack from occurring. Recommended treatment includes blood thinners,
beta blockers, possible angioplasty, heart bypass, bed rest with heart monitoring, as needed (PRN) antiarrhythmics, PRN
anxiolytics, deep vein thrombosis prevention, cardiac rehabilitation, smoke cessation, annual influenza vaccine. Oxygen
and pain relief and nitroglycerin are a part of the first line of treatment (Joffe, 2012).
Prognosis: The prognosis of patients with UA is of a lower in hospital mortality than those with ST elevation myocardial
infarction, however, the long term outcome is similar. How long a patient survives with UA depends on various factors
such as the number of blocked arteries, history of heart attacks, and the hearts ability to pump blood. UA may cause heart
attack, heart failure and dysrhythmias which may cause patients to die unexpectedly (Joffe, 2012).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: aspirin
Trade name: ASA
Route: PO

Concentration

Dosage Amount: 325 mg


Frequency: Once daily

Pharmaceutical class: salicylates

Home

Hospital

or

Both

Indication: The patient presented to the hospital with symptoms of possible myocardial infarction, this medication is for the prophylaxis of myocardial
infarctions and transient ischemic attacks by preventing platelet aggregation.
Adverse/ Side effects: Patient may experience tinnitus, GI bleeding, vomiting, hepatotoxicity, anemia, rash, allergic reactions to include anaphylaxis and
laryngeal edema.
Nursing considerations/ Patient Teaching: Onset is 5-30 minutes with and patient will begin to feel maximum effect 1-3 hours for 3-6 hours. Contraindicated in
patients who are taking other forms of blood thinners as it increases the risk of bleeding. May cause GI irritation so take with food or with a full glass of water.
May cause lengthen bleeding time so prolonged prothrombin time should be monitored. Avoid concurrent use of alcohol to help minimize GI irritation.
Name: atorvastatin
Trade name: Lipitor
Route: PO

Concentration

Dosage Amount: 40 mg
Frequency: Once daily

Pharmaceutical class: hmg coa reductase inhibitors (lipid lowering


Home
Hospital
or
Both
agents)
Indication: Prevents coronary heart disease such as myocardial infarction, stroke, angina, and coronary revascularization from worsening or reoccurring. The
medication will help lower the patients LDL and total cholesterol which stops plaques from building and the advancement of coronary atherosclerosis.

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: Dizziness, headache, rhinitis, chest pain, increased liver enzymes, constipation, hyperglycemia, erectile dysfunction, rashes,
Rhabdomyolysis, and angioneurotic edema are some effects of taking this medication that the patient may experience.
Nursing considerations/ Patient Teaching: Taking this medication may increase the effects of warfarin. Evaluate cholesterol before initiating and periodically
afterwards. Monitor liver function tests prior to and during therapy. If muscle tenderness develops CPK levels should be monitored. Patient should notify
health care professional if unexplained muscle tenderness, pain or weakness occurs.
Name: bisoprolol
Trade name: Zebeta
Route: PO

Concentration

Dosage Amount: 5 mg
Frequency: Once daily

Pharmaceutical class: Beta blockers (antihypertensives)

Home

Hospital

or

Both

Indication: This will help manage the patients hypertension by decreasing blood pressure and heart rate.
Adverse/ Side effects: Patient may experience fatigue, weakness, anxiety, blurred vision, bronchospasm, bradycardia, constipation, increased liver function tests
(LFT), decreased libido, rash, glycemic changes, and back pain.
Nursing considerations/ Patient Teaching: Patient should feel maximum effect within 4 hours and should last approximately 24 hours. Avoid usage of alcohol as
it may cause hypotension. Patients blood pressure, ECG and pulse should be monitored frequently. This medication may cause increase BUN. Patient should
not stop taking this medication abruptly as it may cause life threatening arrhythmias, hypertension and myocardial ischemia. Patient should notify health care
professional if pulse slows, there is difficulty breathing, wheezing, cold hands and feet, dizziness, light headedness, confusion, depression, rash, fever, sore
throat, unusual bleeding or bruising occurs.
Name: enoxaparin
Trade name: Lovenox
Route: Subcutaneous Injection

Concentration

Dosage Amount: 100 mg/ 1 mL


Frequency: q12 hour

Pharmaceutical class: Antithrombotics/ low molecular weight


Home
Hospital
or
Both
heparins
Indication: When used in combination with aspirin this medication will help in preventing ischemic complications such as unstable angina and NSTEMI by
preventing thrombus formation.
Adverse/ Side effects: The patient may experience dizziness, headache, edema, increased liver enzymes, rash, hyperkalemia, bleeding, irritation, pain and fever.
Nursing considerations/ Patient Teaching: The effects of this medication will be optimal within 3-5 hours and will last approximately 24 hours. Patient will have
increased risk of bleeding with use of warfarin, and aspirin. Assess for signs of bleeding and hemorrhage, fall in hematocrit or blood pressure and notify health
care professionals if these occur. Patient should report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling or difficulty
breathing to health care professional (HCP) immediately.
Name: Lisinopril
Trade name: Prinivil, Zestril
Route: PO

Concentration

Dosage Amount: 5 mg
Frequency: Once daily

Pharmaceutical class: Ace inhibitors/ Antihypertensives

Home

Hospital

or

Both

Indication: When used in conjunction with other antihypertensives this medication will help manage hypertension by lowering blood pressure.
Adverse/ Side effects: The patient may experience dizziness, fatigue, cough, hypotension, chest pain, diarrhea, rashes, hyperkalemia and angioedema.
Nursing considerations/ Patient Teaching: This medication will become effective within one hour and achieve therapeutic effect in 6 hours and will last for 24
hours. Nurse should monitor blood pressure (BP) and pulse and notify health care professional of significant changes. Monitor kidney functions. Patient should
notify HCP if rash, mouth sores, sore throat, fever ,sweating of hands and feet, irregular heartbeat, chest pain, dry cough, hoarseness, swelling of face, eyes, lips
or tongue or if difficulty swallowing or breathing occurs.
Name: mexiletine
Trade name: Mexitil
Route: PO

Concentration

Dosage Amount: 200 mg


Frequency: q12hr

Pharmaceutical class: Antiarrhythmics

Home

Hospital

or

Both

Indication: This medication is for the treatment and prevention of serious ventricular arrhythmias.
Adverse/ Side effects: Side effects that this patient may experience include dizziness, nervousness, confusion, blurred vision, dyspnea, arrhythmias, chest pain,
heartburn, rashes and tremor.
Nursing considerations/ Patient Teaching: This medication starts to take effect within 30 minutes 2 hours with maximum effect within 2- 3 hours and lasts for
8-12 hours. The nurse should monitor pulse, BP, ECG and chest x rays to help adjust dosages. Monitor for an increase in AST enzyme. Patients should be
taught how to monitor pulse and to contact HCP if pulse rate is less than 50 beats per minute or becomes irregular.
Name: nitroglycerin
Trade name: Nitrostat
Route: sublingual

Concentration

Dosage Amount: 0.4 mg


Frequency: q5min PRN chest pain

Pharmaceutical class: Nitrates/ antianginals

Home

Hospital

or

Both

Indication: This medication relieves myocardial oxygen consumption to prevent or relieve angina attacks.
Adverse/ Side effects: The patient may experience side effects of dizziness, headache, restlessness, blurred vision, hypotension, tachycardia, nausea, and
vomiting.
Nursing considerations/ Patient Teaching: This medication has a rapid onset that occurs within 3 minutes and the effects can last 30-60 minutes. The patient

University of South Florida College of Nursing Revision September 2014

should be aware that tablet should not be swallowed or crushed but should be allowed to dissolve under the tongue. The nurse should be aware that 3 doses of
this medication should be administered 5 minutes apart or until chest pain resolves. Patient should be aware that they may experience the worst headache of
their life. The nurse should monitor BP and pulse before and after administration. The nurse should also assess the patients angina pain.
Name: ondansetron
Trade name: Zofran
Route: IV Injection

Concentration

Dosage Amount: 4mg/ 2 mL


Frequency: q4hour PRN nausea/ vomiting

Pharmaceutical class: five ht3 antagonists/ antiemetic

Home

Hospital

or

Both

Indication: This medication is for the prevention of any nausea and vomiting the patient may experience.
Adverse/ Side effects: Patient may experience headache, dizziness, QT interval prolongation, constipation, diarrhea, extrapyramidal reactions and an increase
in liver enzymes.
Nursing considerations/ Patient Teaching: The onset of this medication is rapid with a peak of 15- 30 minutes that may last 4-8 hours. The nurse should assess
patient for nausea, vomiting, abdominal distention and bowel sounds prior to and after administration. Patient should be instructed to notify HCP if irregular
heart beat or involuntary movement of eyes, faces, or limbs occur.
Name: warfarin
Trade name: Coumadin
Route: PO
Pharmaceutical class: coumarins/ anticoagulants

Concentration

Dosage Amount: 8 mg
Frequency: Once daily
Home

Hospital

or

Both

Indication: The patient had a pacemaker placed and this medication will help in preventing formation of thrombus and embolization after valve replacement.
Adverse/ Side effects: Patient may experience cramps, nausea, bleeding and fever.
Nursing considerations/ Patient Teaching: This medication has an onset of 36-72 with a peak duration within 5-7 days with constant usage and this effect can
last 2-5 days. This drug will increase the response to warfarin and increase the risk of bleeding when used with NSAIDs and aspirin. The patient should tell the
HCP if they are using anise, arnica, chamomile, clove, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, licorice as these may also increase
risk of bleeding. The nurse should assess for bleeding and hemorrhage such as bleeding gums, nosebleed, unusual bleeding, tarry- black stools, hematuria, fall in
hematocrit or BP, urine or nasogastric aspirate. Monitor PT, INR and other clotting factors. Patient should report any symptoms of unusual bleeding and
should not drink alcohol or other medications unless prescribed by HCP.

University of South Florida College of Nursing Revision September 2014

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: On a typical morning, the patient eats one slice
of ham cold cuts and one slice of American cheese
sandwich on two slices of white toasted bread with an 8
ounce of decaffeinated coffee containing milk and sugar.
Lunch: For lunch, the patient eats two ham and cheese
sandwiches with mayo.
Dinner: For dinner the patient may consume a handful of
white rice, roasted pork with avocado salad with no
dressing.
Snacks: The patient does not normally eat snacks
throughout the day as he doesnt get hungry.
Liquids (include alcohol): The patient consumes about
three cups of 16 ounce water throughout the day.

Analysis of home diet (Compare to My Plate and


Consider co-morbidities and cultural considerations):
The recommended daily consumption of calories is 2000
Calories, the patient consumed 1458 Calories. Fifteen percent of
calories were proteins which was within the 10- 35%
recommended range. The patients carbohydrate consumption was
149 g, above the 130 g recommended consumption. Dietary fiber
consumption was 7 g, under the recommended 25 g. The total fat
of the days food was 43% of the Calories, above the 20- 35 %
Calorie recommendation. The saturated fat consumption should
be less than 10 percent of the calories, however the patients
meals totaled 14%. Cholesterol for the day was below the
recommended 300 mg at 156 mg. The patients sodium
consumption for the day was over the daily recommended
amount of less than 2300mg at 3891 mg instead. The patient has
a history of hypertension, has congenital heart disease, is
overweight and cannot exercise because of his heart. His diet
should include more fiber to help make his bowel movements
easier, less saturated fat and cholesterol as they play a role in
heart disease, and with the patients history of hypertension his
sodium consumption should be lower than 1500 and it is
appropriate for his calorie consumption to be below 2000 because
he leads a sedentary life and is unable to exercise as
aforementioned.
My recommendation for a meal is below. If the patient follows
the dietary his meals will be more balanced. The patients total
calorie consumption would be 1302, protein would be over the 46
g recommendation at 67 g, and protein would be 20% of 10-35%
calorie recommendation. Carbohydrate consumption would be
194g of the 130 g recommendation; 60% of the calories would be
from carbohydrates within the recommended 45-65% amount.
Twenty five grams is the recommended consumption of dietary
fiber and the patient would consume 23 grams. Total fat
consumption would be 21% of calories within the 20-35% calorie
recommendation of which 7% was saturated fats, below the 10%
suggestion. The patient would consume below 300 mg of
cholesterol at 103 mg. The patients sodium consumption would
be 1374 mg, within the suggested range, below 2300 mg.

University of South Florida College of Nursing Revision September 2014

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patient states, my fianc and children, my parents live down South so they cant
help much.
How do you generally cope with stress? or What do you do when you are upset? The patient states that he, secludes
himself.

University of South Florida College of Nursing Revision September 2014

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) The patient
denies any recent difficulties.

+2 DOMESTIC VIOLENCE ASSESSMENT


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_____________
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? ______________________
Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust


Intimacy vs. Isolation

Autonomy vs.
Generativity vs.

Doubt & Shame


Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: According to Social Work Perspectives on Human Behaviour, the stage of generativity versus stagnation is
defined by making contributions to family and society. This stage is marked by the individuals ability to raise a family and work, to
meet their needs and those of others with a balance. Generativity encompasses an ability to foresee and hope for the future. The central
point is parenting and productivity with a desired outcome of care and possibility of having negative outcomes to include overextension, exhaustion, and rejection (Parrish, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the generativity stage. He is was a part of the workforce for years before moving to Florida and now he is
an active parent in his childrens life. Although he is not working, he still meets the needs of his family.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The main impact the complications of his heart condition has had on his life is impeding his ability to be a part of the
workforce but the patient has taken it all in stride and displays no regret or bitterness.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient states that he does not know what the cause of his illness is. There is no history of heart conditions in his
family and he was the only one born with any illness.
What does your illness mean to you?
The patient states, I was born with it, I had my first operation at 2 years old, it is a part of my life.

+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________________________________________________________________

University of South Florida College of Nursing Revision September 2014

Do you prefer women, men or both genders? The patient prefers women______________________________________
Are you aware of ever having a sexually transmitted infection? _No_________________________________________
Have you or a partner ever had an abnormal pap smear? ___No______________________________________ Have you
or your partner received the Gardasil (HPV) vaccination? The patient does not know._____________________________
Are you currently sexually active? Yes________________________ If yes, are you in a monogamous relationship?
__Yes________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? None__________________________
How long have you been with your current partner?5 years._________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? The patient states that it definitely
has not.__________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision September 2014

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


What importance does religion or spirituality have in your life?
The patient states, I am at a stage in life right now where religion is questionable, I am not sure where in my life it fits.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
The patient states, no, my mentality helps me to cope.
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:


1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Newports
1.5 packs every other day

Yes
No
For how many years? 20 years
(age 12

thru 32

If applicable, when did the


patient quit? The patient stopped
smoking 4 years ago.

Pack Years: 1
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit?


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

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? 6 beers
Scotch:
Volume: 16 ounce glass of scotch
Frequency: scotch at least once per
week
If applicable, when did the patient quit? N/A Socially: Beer once every 3 months.

For how many years?


(age 14

thru

presently

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much?
For how many years? 12
(age 20
thru 32
)
2 blunts per day
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?


The patient quit four years ago.

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
5. For Veterans: Have you had any kind of service related exposure? Not applicable.

University of South Florida College of Nursing Revision September 2014

10

10 REVIEW OF SYSTEMS NARRATIVE


Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: Patient does
not use SPF
Bathing routine: Once daily
Other:

Be sure to answer the highlighted area


HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2x/day
Routine dentist visits
12x/year
Vision screening
2 years ago
Other:

Immunologic

Nausea, vomiting, or diarrhea


Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis

Chills with severe shaking


Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor

Diverticulitis

Life threatening allergic reaction

Appendicitis
Abdominal Abscess
Last colonoscopy? Two years ago
Other:

Enlarged lymph nodes


Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A+
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

4x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 01/19/2015
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System


WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam? Four years
ago
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

11

Last EKG screening, when?


Other:

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Patient states that his health is as good as can be with everything thats going on.

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

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10 PHYSICAL EXAMINATION:
General Survey: Patient
Height: 175.26 inches Weight: 215 pounds/
BMI: 32
Pain: (include rating and
is well developed 36 year
97.471 kg
location) O
old who is slightly
Pulse: 89
Blood Pressure: (include location)
overweight.
111/74 left arm
Respirations: 17
Temperature: (route
SpO2: 98
Is the patient on Room Air or O2 :
taken?) 98.2 oral
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
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?

flat
loud

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- 24 inches & left ear- 24 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL: clear
LUL: clear
RML : clear
LLL: clear
RLL: clear

Chest expansion

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

Cardiovascular:

No lifts, heaves, or thrills

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Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative


Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid: 2
Brachial: 3
Radial: 3
Femoral:
Popliteal:
DP: 2
PT:
No temporal or carotid bruits
Edema:
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date 01 /19/2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output:


without assistance

or

mLs N/A

with assistance

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 paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs 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:

Patellar: 2

Achilles:

Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
University of South Florida College of Nursing Revision September 2014

14

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
WBC: 6.0
Normal: 4.511.1

Dates
01/19/2015

Trend
Upon admission, the
patients WBCs were
within normal limits.

HGB: L13.9
Normal: 11.716.1 g/dL

01/19/2015

Upon admission, the


patients hemoglobin
(HGB) levels were
within normal range
although by this
particular hospitals
standards it was low.

PLT: 196
Normal: 150450
103/microL

01/19/2015

Upon admission, the


patients platelet (PLT)
count was within
normal range.

Coagulation:
PT: H21.9
INR: 1.9
APTT: H36.1

01/19/2015
01/19/2015
01/19/2015

Upon admission the


patients clotting time
was longer than the
normal 25- 30 seconds
(Healthline, 2014).

Analysis
High WBC indicate an
infectious process is
ongoing. The patients
normal levels indicate an
absence of infection
(Vallerand, 2014).
Low HGB indicates
oxygen isnt being
circulated as it should
hence causing the organs
to not be adequately
perfused. The patients
HGB levels could be an
indicator of oxygenation
problems (Vallerand,
2014).
PLTs are an important
factor in the bodys
clotting mechanism. The
patient is on blood
thinners. If there are not
enough PLTs, the patient
may bleed and/ or bruise
easily. The inverse of
having too high a levels
of PLT would contribute
to blood clots and
arteriosclerosis. The
patients levels were
normal (Vallerand, 2014).
The patient is on multiple
medications that may
affect his bodys clotting
mechanism. Aspirin may
increase PT and warfarin
requires monitoring of
clotting factors. The
patients lengthened
clotting time is a side
effect of his blood
thinners and an indication
that his medication

University of South Florida College of Nursing Revision September 2014

15

dosage should be adjusted


(Pietrangelo, 2013)
(Thompson. 2014)
BUN: 20
normal (7-20 mg/dl)

01/19/2015

Creatinine: 0.87
normal(0.5-1.4 mg/dl)

01/19/2015

Troponin-I: <0.015
0.015

01/19/2015
01/20/2015

BN Peptide: 67.8
<100 indicate no HF,
100-300 suggest heart
failure is present
LFT: Test not done
AST
ALT

01/19/2015

N/A

The patients blood urea


nitrogen levels were on
the higher side of
normal upon admission.

BUN tests the nitrogen in


the blood from urea
breakdown. The patient is
on beta blockers which
have a side effect of
increased BUN. A high
BUN is an indication of
kidney insufficiency.
Because of his high BUN
the patient needs to be
decrease his protein
intake (Vallerand, 2014)
The patients normal
Upon admission the
creatinine levels indicate
patients creatinine
an absence of chronic
levels were in normal
kidney disease and also
range.
indicates creatinine is
being cleared from the
blood (Vallerand, 2014).
Troponin I is a cardiac
The patients troponin
marker that is released
levels are low; the
when heart muscles have
patient has negative
been damaged like during
troponins.
a heart attack. The patient
came to the ER because
of angina that did not
resolve with rest. These
troponin levels indicate
that there has been no
heart damage (Chen,
2014).
The patients BNP levels The patients BNP levels
are less than 100 which helps to rule out possible
heart failure (Vallerand,
is within normal limits.
2014).
I would expect to see a
liver function test
conducted because the
patient takes
antiarrhythmics at home
and Lipitor since being
admitted, both of which
affect liver enzymes and
require LFT monitoring.
An increased level would

University of South Florida College of Nursing Revision September 2014

16

Lipid Panel: Test not


done
Normal values:
Total cholesterol <200
HDL >60
LDL<100
Triglycerides <200
Ratio: <4.5

N/A

indicate potential liver


damage (Vallerand,
2014).
I would expect to see a
lipid panel because the
patient is on cholesterol
medications which
require cholesterol
monitoring. Increased
LDL cholesterol
increases ones risk of
heart disease (Derrer,
2013).

Chest X ray conducted on 01/19/2015 because of chest pain revealed symmetrical lungs without consolidation,
pneumothorax or pleural fluid. Cardio mediastinal silhouette size is on the larger side of normal size. The
presence of a dual lead upper chest wall cardiac pacer was seen. Median sternotomy was done. The general
impression of this x ray confirmed there was no cardiopulmonary process.
Electrocardiogram was done on 01/19/2015 and showed a heart rate of 82, normal sinus rhythm with a first
degree AV block, St and T wave abnormalities, abnormal PR interval of 232 and normal QRS duration of 110.
Normal sinus rates would have revealed a PR interval of 0.12-0.21, QRS duration of 0.06- 0.12
Ultrasound was done on 01/20/2015 but the results were not interpreted before clinical day ended.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,
multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently on vital signs every 4 hours. He is also on a cardiac diet during his hospital stay.
The patient is not on fall risk precautions and can ambulate independently. The patient was scheduled for
a stress test and was awaiting a consult with his pediatric cardiologist before he would be discharged from
the hospital.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. At risk for bleeding r/t impaired clotting aeb patient confirmation of bleeding and bruising easily.
2. Imbalanced nutrition: more than body requirements r/t poor dietary intake aeb BMI over 25
3. Decreased cardiac output r/t cardiac dysfunction (dysrhythmia) aeb ECG reading and patients complaint chest pain
4. Activity intolerance r/t sedentary lifestyle aeb patient fatigue upon exertion
5. Risk for decreased cardiac tissue perfusion r/t pacemaker malfunction

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17

15 CARE PLAN
Nursing Diagnosis: At risk for bleeding r/t impaired clotting aeb patient confirmation of bleeding and bruising easily.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
The patient will maintain stable
-Assess client for signs and
- By knowing the early and late
-There was no change in the
vital signs during time on floor.
symptoms of unusual bleeding
signs and symptoms of bleeding
patients vital signs, goal was met.
such as decreased B/P, bruising
the nurse can correct it from
and increase pulse rate and a
earlier.
decrease in hematocrit and
-Watch for changes associated with
hemoglobin levels.
bleeding including increased heart
-Check vital signs at frequent
rate, respiratory rate, and
intervals
eventually decreased blood
-Implement measures to prevent
pressure.
bleeding such as using the smallest - Preventing bleeding will help the
gauge needles and apply gentle
patient maintain stable vital signs
prolonged pressure to the site after
(Pomeroy, 2011).
needle is removed)
Lab values related to bleeding will - Monitor laboratory tests including - INR and PT measure the effects
- The patients PT and aPTT values
remain normal throughout hospital hematocrit, hemoglobin, INR, PT.
of medication on the coagulation
were slightly elevated, this goal is
stay.
-Monitor medications for effects on cascade and should be drawn at
still in progress and hence has not
increasing bleeding including
least 16 hours after the dose is
been met.
aspirin and NSAIDs.
administered.
-These medications have an
antiplatelet effect that can increase
the risk of bleeding especially in a
client who is at risk due to illness
or medications.
(Pomeroy, 2011).
Patient to prevent bleeding after
- **Educate patient on signs such
- Shave with an electric razor.
-Goal not met, the patient has been
discharge from hospital.
as nosebleed and abnormal
Brush teeth with a soft toothbrush. discharged from the hospital as yet.
bruising.
Wipe with wet wipes after stooling.
- Advise patient to adopt safety
Avoid sports and activities that
practices about self- care activities. could increase the patients risk for
-**Teach patient to monitor the
falling.
University of South Florida College of Nursing Revision September 2014

18

intake of foods, herbs, and dietary


supplements.

-Foods high in vitamin K (spinach,


broccoli, cauliflower, cabbage) can
decrease the effect of the
medication. Increased activity will
decrease the effect of warfarin.
Illness, herbal supplements will
increase the effect of warfarin.
(Pomeroy, 2011).

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult - yes
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments - yes
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

Nursing Diagnosis: Imbalanced nutrition: more than body requirements r/t poor dietary intake aeb BMI over 25
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will recognize measures
-Document weight.
- Patient may be unaware of actual -This goal was met as patient was
necessary to achieve weight
-Familiarize the patient with selfweight and will be able to track
able to demonstrate understanding
reduction during shift.
monitoring of food intake
progress.
of measures necessary to achieve
including keeping a food and
- A Cochrane review found that
weight reduction.
exercise diary.
cognitive behavior therapy when
-Planning food intake for each day. combined with a diet and exercise
- Encourage client to increase
intervention resulted in more
intake of vegetables and fruits to at weight loss than diet and exercise
least five servings per day.
alone.
-A study demonstrated that
University of South Florida College of Nursing Revision September 2014

19

Patient will design dietary


modifications toward goal of
weight reduction throughout shift
on floor.

- Bringing only healthy foods into


the house to decrease temptation.
- Perform nutritional assessment
-Assess ability to read food labels.
-Assess ability to plan a menu,
making appropriate food
selections.

Patient will increase activity level


upon discharge from hospital.

-Assess for reasons the patient


would not be able to participate in
an exercise regimen, refer for
evaluation by HCP.
-Changing ones mindset by
encouraging activity to help with
weight loss.
-Recommend the patient begin a
walking program by buying a
pedometer, determine times
walking can be incorporated into
usual lifestyle, setting a goal of
steps to walk per day.

increased fruit and vegetable intake


decreased risk of obesity.
(Pomeroy, 2011).
-This should include types and
- Goal met, the patient was able to
amount of foods eaten, food
outline dietary modifications.
preparation, the time/ frequency
patient is engaged in while eating.
-Cultural or ethnic influences need
to be identified and addressed.
(Pomeroy, 2011).
-This will ensure that the patients
- Goal not met, the patient had not
efforts to increase activity levels do been discharged from the hospital
not overwork his heart.
as yet.
- A study demonstrated that
walking more decreases BMI.
-A systematic review found that the
use of pedometers resulted in
increased physical activity.
(Pomeroy, 2011).

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult - yes
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
University of South Florida College of Nursing Revision September 2014

20

Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

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References

Chen, M. (2014, January 17). Troponin test: medlineplus medical encyclopedia (D. Zieve & B. Black, Eds.).
Retrieved February 14, 2015,from http://www.nlm.nih.gov/medlineplus/ency/article/007452.htm
Derrer, D. (2013, March 27). Tests for high cholesterol (lipid panel). Retrieved February 14, 2015, from
http://www.webmd.com/cholesterol-management/tests-for-high-cholesterol-lipid-panel?page=2
Joffe, MD, S., & Berk, MD, L. (2012, January 1). Acute coronary syndromes: unstable angina and nstemi.
Retrieved February 12, 2015, from http://nursing.unboundmedicine.com/nursingcentral/view/5-MinuteClinical-Consult/117673/all/Acute_Coronary_Syndromes:_Unstable_Angina_and_
NSTEMI?q=unstable angina
K. Pai., R., Fort., & Healthline Staff (2014, March 12). heart attack and unstable anginatreatment overview. Retrieved February 12, 2015, from http://www.webmd.com/heart-disease/tc/heartattack-and-unstable-angina-treatment-overview
"MyPlate.gov" SuperTracker. united states department of agriculture. Web. 21 November 2014.
<https://www.supertracker.usda.gov/foodtracker.aspx
Parrish, M. (2014). Freud's psychoanalytical and Erikson's developmental theories of behaviour. In social work
perspectives on human behaviour (2nd ed., pp. 77-82). Maidenhead: McGraw-Hill Education.
Pietrangelo, A., & Krucik, (2013, January 20). Coagulation tests. Retrieved February 16, 2015,
from http://www.healthline.com/health/coagulation-tests#Types3
Pomeroy, S. & Ackley, B. J., Ladwig, G. B., (2011). Risk for bleeding and imbalanced nutrition: more than
body requirements. Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.,
p169- 171) (p582-587). Maryland Heights, Mo.: Mosby.
Thompson, MD, E., O'Donnell, MD, J., & Staff, H. (2014, March 12). Partial thromboplastin time. Retrieved
February 14, 2015,from http://www.webmd.com/a-to-z-guides/partial-thromboplastin-time?page=2

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Vallerand, A., Sanoski, C., & Deglin, J. (2014). [aspirin (ASA) to warfarin (Caumadin)] [Normal values of
common laboratory tests] Daviss Drug Guide. Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central

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