UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING

1tudent; Brian (oirier

PATIENT ASSESSMENT TOOL . 1 PATIENT INFORMATION

(atient Initials; =ender; 6 3.#. #ge; <+ >arital 1tatus; 1ingle

#ssignment !ate; +-+/-/0 #gency; Bayfront

#dmission !ate; +-+7-/0 (rimary >edical !iagnosis with I"!)/7 code; I?7.0 Other >edical !iagnoses; (new on this admission'

(rimary anguage; 3nglish evel of 3ducation; Bachelors !egree Occu&ation (if retired, what from@'; $etired kindergarten teacher 9umber-ages children-siblings; / sister who has &assed away.

1erved-Aeteran; 9o iving #rrangements; Bestminster 1hores. ives by herself in a ground level a&artment with no stairs. "ulture- 3thnicity -9ationality; "aucasian, 81# $eligion; (resbyterian

"ode 1tatus; 6ull #dvanced !irectives; yes If no, do they want to fill them out@ 1urgery !ate; (rocedure;

%y&e of Insurance; ##$(

1 CHIEF COMPLAINT: I had a constant thick cough for about a month, they said I had bronchitis but I guess theyre saying that I have heart failure now.

3 HISTORY OF PRESENT ILLNESS: (Be sure to O !"#$% the sym&toms in addition to the hos&ital course'
(atient went to her &rimary care &hysician in mid)*anuary with com&laints of a cough for about + weeks and was treated with a ,)&ack. %he &atient did not im&rove and on +-.-/0 went to 1aint #nthonys 2os&ital 3$ for continued &roductive coughing and dys&nea. 1he was treated with e4&ectorant and sent home. ast week she called her &rimary &hysician again and was referred to have a "5$. 2er &hysician diagnosed her with "26 after viewing the "5$ and started her on a low dose (O asi4 schedule. %oday ( +7th' she followed u& with her &hysician with no signs of im&rovement. %he &atient was then referred Bayfront hos&ital and admitted since she has shown no sign of im&rovement. (atient denies any recent weight gain, and has lost +7 lbs. in the last month.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hos&italiCations for any medical illness or o&eration
Date (atient could not remember e4act dates but was able to give a&&ro4imates. 3arlier than +770 1ince +770. Operat !" !r I##"e$$

#m&utated finger, "arotid endarterectomy, O$I6, 1Duamous cell carcinoma, !eviated 9asal se&tum, hy&ertension, osteo&orosis, arthritis, %I#. ###, #nemia, !e&ression, #)fib, hy&erli&idemia, slee& a&nea.

(angina, >I, !A% etc.' 2eart %rouble

Eidney (roblems

3nvironmental #llergies

>ental (roblems 2ealth

"ause of !eath (if a&&licable '

1tomach 8lcers

Bleeds 3asily

2y&ertension

#lcoholism

=laucoma

!iabetes

2 FAMILY MEDICAL HISTORY

6ather >other Brother 1ister
relationshi& relationshi& relationshi&

#ge (in years'

#rthritis

1eiCures

#nemia

#sthma

"ancer

</ <0 died in slee&

FF

"omments; Include date of onset (atient believes sister died of a second stroke in her slee&, she does not have &roof, but feels since she had one stroke she might have had a big one in her slee&.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

%umor

1troke

=out

 1 IMMUNI%ATION HISTORY (>ay state 8 for unknown, e4ce&t for %etanus, 6lu, and (na' $outine childhood vaccinations $outine adult vaccinations for military or federal service #dult !i&htheria (!ate' #dult %etanus (!ate' 8nsure but within /7 years InfluenCa (flu' (!ate' (neumococcal (&neumonia' (!ate' 2ave you had any other vaccines given for international travel or occu&ational &ur&oses@ (lease ist 1 ALLERGIES OR ADVERSE REACTIONS
9#>3 of "ausative #gent 2ydrochlorothiaCide 1ulfa allergy >edications

YES

NO

%y&e of $eaction (describe e4&licitly' Itching swelling and redness of skin. Itching swelling and redness of skin.

Other (food, ta&e, late4, dye, etc.'

& PATHOPHYSIOLOGY: (include #(# reference and in te4t citations' (>echanics of disease, risk factors, how to diagnose, how to treat, &rognosis, and include any genetic factors im&acting the diagnosis, &rognosis or treatment'
2eart failure is caused by any condition which reduces the efficiency of the myocardium, or heart muscle, through damage or overloading. #s such, it can be caused by a wide number of conditions, including myocardial infarction (in which the heart muscle is starved of o4ygen and dies', hy&ertension (which increases the force of contraction needed to &um& blood' and amyloidosis (in which &rotein is de&osited in the heart muscle, causing it to stiffen'. Over time these increases in workload will &roduce changes to the heart itself (2eart 6ailure +7/0'. %hese changes (reduced force of contraction, reduced stroke volume, increased heart rate, hy&ertro&hy and enlargement of the ventricles' work together to result in an overall decrease in cardiac out&ut, which serves to increase the demand on the heart which increases the risk of cardiac arrest and organ failure due to hy&o&erfusion. In systolic dysfunction, the body activates several neurohormonal &athways to increase circulating blood volume. %he sym&athetic nervous system increases heart rate and contractility, causes arteriolar vasoconstriction in nonessential vascular beds, and stimulates secretion of renin from the Gu4taglomerular a&&aratus of the kidney. 8nfortunately, catecholamines aggravate ischemia, &otentiate arrhythmias, &romote cardiac remodeling, and are directly to4ic to myocytes. 1timulation of the renin)angiotensin system as a result of increased sym&athetic stimulation and decreased renal &erfusion results in further arteriolar vasoconstriction, sodium and water retention, and release of aldosterone. #n increased aldosterone level, in turn, leads to sodium and water retention, endothelial dysfunction, and organ fibrosis. $isk factors for "26 include; hy&ertension, coronary artery disease, diabetes mellitus, family history of cardiomyo&athy, use of cardioto4ins, and obesity. %he initial evaluation of new)onset heart failure should include an electrocardiogram, chest radiogra&h, and B9( assay. 3E= findings of A hy&ertro&hy, left bundle branch block, intraventricular conduction delay, and nons&ecific 1%)segment and % wave changes su&&ort a diagnosis of heart failure (2obbs and Boyle +7/0'. Initially a set of obGective signs and sym&toms may &resent before the &atient is aware of heart failure; !ys&nea, cyanosis, &roductive cough, ortho&nea, dys&nea on e4ertion and &eri&heral edema may all result from "26. ifestyle modifications must be enacted in combination to any &harmacological treatment regimeH +)g 1odium diet, >onitoring weight daily, +) 6luid restriction, >onitoring blood &ressure, and smoking cessation should all be considered. (harmacological management includes medications such as; !iuretics and

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

#ce Inhibitors to decrease fluid retention and increase diuresis to normaliCe fluid volumes. Beta blockers are used to decrease heart rate and therefore decrease myocardial O+ demand. 2obbs and Boyle state that the e4act nature of their action is unknown. %he e4act mechanism of beta blocker action is unclear, but it likely involves antiarrhythmic, anti) ischemic, anti)remodeling, and anti)a&o&totic &ro&erties, as well as im&roved beta rece&tor &athway function. >yocardial o4ygen consum&tion is reduced with beta blockers, &rimarily because of a reduction in heart rate (2obbs and Boyle +7/0'. 2eart failure can only be cured by a heart trans&lantH &revention and early detection are its greatest defenses. (atients with heart failure will live with and must manage their heart failure with medications and lifestyle modifications to &revent &remature e4acerbation.

& MEDICATIONS: IInclude both &rescri&tion and O%"H home (reconciliation', routine, and ($9 medication. =ive trade and
generic name.J
Na'e A#()ter!# : i&ratro&ium (!uo9eb' R!)te (O nebuliCer treatment. P0ar'a*e)t *a# *#a$$ a1re"er, *$ C!"*e"trat !" +',/'#- 7.? mg -. ml inhalation solution Fre.)e"*/ DKh H!'e H!$p ta# !r 2!t0 D!$a,e A'!)"t +',-

I"1 *at !": 8sed as a bronchodilator to control and &revent reversible airway obstruction caused by asthma or "O(!. Inhaln; 8sed as a Duick)relief agent for acute bronchos&asm and for &revention of e4ercise)induced bronchos&asm. (O; 8sed as a long)term control agent in &atients with chronic-&ersistent bronchos&asm. S 1e e33e*t$: "91; nervousness, restlessness, tremor, headache, insomnia ((edi; occurs more freDuently in young children than adults', hy&eractivity in children $es&; (#$#!O5I"# B$O9"2O1(#1> (35"311IA3 813 O6 I92# 3$1', "A; chest &ain, &al&itations, angina, arrhythmias, hy&ertension, =I; nausea, vomiting, 3ndo; hy&erglycemia, 6 and 3; hy&okalemia, 9euro; tremor. N)r$ ", *!"$ 1erat !"$: I"$tr)*t pat e"t t! ta4e a#()ter!# a$ 1 re*te1. I3 !" a $*0e1)#e1 1!$ ", re, 'e"5 ta4e ' $$e1 1!$e a$ $!!" a$ re'e'(ere15 $pa* ", re'a " ", 1!$e$ at re,)#ar "ter6a#$. D! "!t 1!)(#e 1!$e$ !r "*rea$e t0e 1!$e !r 3re.)e"*/ !3 1!$e$. Ca)t !" pat e"t "!t t! e7*ee1 re*!''e"1e1 1!$e8 'a/ *a)$e a16er$e e33e*t$5 para1!7 *a# (r!"*0!$pa$' +'!re # 4e#/ 9 t0 3 r$t 1!$e 3r!' "e9 *a" $ter-5 !r #!$$ !3 e33e*t 6e"e$$ !3 'e1 *at !". I"$tr)*t pat e"t t! *!"ta*t 0ea#t0 *are pr!3e$$ !"a# ''e1 ate#/ 3 $0!rt"e$$ !3 (reat0 $ "!t re# e6e1 (/ 'e1 *at !" !r $ a**!'pa" e1 (/ 1 ap0!re$ $5 1 :: "e$$5 pa#p tat !"$5 !r *0e$t pa ". I"$tr)*t pat e"t t! pr 'e )" t 9 t0 ; $pra/$ (e3!re )$ ", a"1 t! 1 $*ar1 *a"" $ter a3ter 2<< $pra/$. A*t)at!r$ $0!)#1 "!t (e *0a",e1 a'!", pr!1)*t$. I"3!r' pat e"t t0at t0e$e pr!1)*t$ *!"ta " 0/1r!3#)!ra#4a"e +HFA- a"1 t0e pr!pe##a"t a"1 are 1e$*r (e1 a$ "!"=CFC !r CFC=3ree +*!"ta " "! *0#!r!3#)!r!*ar(!"$-. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e" a"1 t! *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ OTC 'e1 *at !"$ !r a#*!0!# * (e6era,e$ *!"*)rre"t#/ 9 t0 t0 $ t0erap/. Ca)t !" pat e"t a#$! t! a6! 1 $'!4 ", a"1 !t0er re$p rat!r/ rr ta"t$. I"3!r' pat e"t t0at a#()ter!# 'a/ *a)$e a" )")$)a# !r (a1 ta$te. I"$tr)*t pat e"t " t0e pr!per )$e !3 t0e 'etere1=1!$e "0a#er !r "e()# :er +$ee 'e1 *at !" a1' " $trat !" te*0" .)e$-. A16 $e pat e"t$ t! )$e a#()ter!# 3 r$t 3 )$ ", !t0er "0a#at !" 'e1 *at !"$ a"1 a##!9 & ' " t! e#ap$e (e3!re a1' " $ter ", !t0er "0a#a"t 'e1 *at !"$ )"#e$$ !t0er9 $e 1 re*te1. A16 $e pat e"t t! r "$e '!)t0 9 t0 9ater a3ter ea*0 "0a#at !" 1!$e t! ' " ' :e 1r/ '!)t0 a"1 *#ea" t0e '!)t0p e*e 9 t0 9ater at #ea$t !"*e a 9ee4. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 t0ere $ "! re$p!"$e t! t0e )$)a# 1!$e !r 3 *!"te"t$ !3 !"e *a" $ter are )$e1 " #e$$ t0a" 2 94. A$t0'a a"1 treat'e"t re, 'e" $0!)#1 (e re=e6a#)ate1 a"1 *!rt *!$ter! 1$ $0!)#1 (e *!"$ 1ere1. Nee1 3!r "*rea$e1 )$e t! treat $/'pt!'$ "1 *ate$ 1e*rea$e " a$t0'a *!"tr!# a"1 "ee1 t! ree6a#)ate pat e"t>$ t0erap/. Pe1 : Ca)t !" a1!#e$*e"t$ a"1 t0e r pare"t$ a(!)t !6er)$e !3 "0a#er$5 90 *0 *a" *a)$e 0eart 1a'a,e a"1 # 3e=t0reate" ", arr0/t0' a$. Na'e A'#!1 p "e R!)te P.O. P0ar'a*e)t *a# *#a$$: Ca#* )' C0a""e# 2#!*4er I"1 *at !": #lone H!'e C!"*e"trat !" Fre.)e"*/ 1 ta( 1a #/ H!$p ta# !r 2!t0 D!$a,e A'!)"t 1<',

or with other agents in the management of hy&ertension, angina &ectoris, and vasos&astic ((rinCmetalLs' angina.

S 1e e33e*t: CNS: 1 :: "e$$5 3at ,)e5 CV: per p0era# e1e'a5 a", "a5 (ra1/*ar1 a5 0/p!te"$ !"5 pa#p tat !"$5 GI: , ", 6a# 0/perp#a$ a5 "a)$ea5 Der': 3#)$0 ", /N)r$ ", *!"$ 1erat !"$: 16 $e pat e"t t! ta4e 'e1 *at !" a$ 1 re*te15 e6e" 3 3ee# ", 9e##. Ta4e ' $$e1 1!$e$ a$ $!!" a$ p!$$ (#e )"#e$$ a#'!$t t 'e 3!r "e7t 1!$e8 1! "!t 1!)(#e 1!$e$. Ma/ "ee1 t! (e 1 $*!"t ")e1 ,ra1)a##/. A16 $e pat e"t t! a6! 1 #ar,e a'!)"t$ +?@A ,#a$$e$ !3 ,rape3r) t B) *e/1a/- 1)r ", t0erap/. I"$tr)*t pat e"t !" *!rre*t te*0" .)e 3!r '!" t!r ", p)#$e. I"$tr)*t pat e"t t! *!"ta*t 0ea#t0 *are pr!3e$$ !"a# 3 0eart rate $ C&< (p'. Ca)t !" pat e"t t! *0a",e p!$ t !"$ $#!9#/ t! ' " ' :e !rt0!$tat * 0/p!te"$ !". Ma/ *a)$e 1r!9$ "e$$ !r 1 :: "e$$. A16 $e pat e"t t! a6! 1 1r 6 ", !r !t0er a*t 6 t e$ re.) r ", a#ert"e$$ )"t # re$p!"$e t! t0e 'e1 *at !" $ 4"!9". I"$tr)*t pat e"t !" 'p!rta"*e !3 'a "ta " ", ,!!1 1e"ta# 0/, e"e a"1 $ee ", 1e"t $t 3re.)e"t#/ 3!r teet0 *#ea" ", t! pre6e"t te"1er"e$$5 (#ee1 ",5 a"1 , ", 6a# 0/perp#a$ a +,)' e"#ar,e'e"t-. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e"5 t! a6! 1 a#*!0!#5 a"1 t! *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ "e9 'e1 *at !"$5 e$pe* a##/ *!#1 preparat !"$. A16 $e pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 rre,)#ar 0eart(eat$5 1/$p"ea5 $9e## ", !3 0a"1$ a"1 3eet5 pr!"!)"*e1 1 :: "e$$5 "a)$ea5 *!"$t pat !"5 !r 0/p!te"$ !" !**)r$ !r 3 0ea1a*0e $ $e6ere !r per$ $te"t. Ca)t !" pat e"t t! 9ear pr!te*t 6e *#!t0 ", a"1 )$e $)"$*ree" t! pre6e"t

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

p0!t!$e"$ t 6 t/ rea*t !"$. A16 $e pat e"t t! "3!r' 0ea#t0 *are pr!3e$$ !"a# !3 'e1 *at !" re, 'e" (e3!re treat'e"t !r $)r,er/. I"$tr)*t pat e"t !" *!"*)rre"t " trate !r (eta=(#!*4er t0erap/ t! *!"t ")e ta4 ", (!t0 'e1 *at !"$ a$ 1 re*te1 a"1 t! )$e SL " tr!,#/*er " a$ "ee1e1 3!r a", "a# atta*4$. A16 $e pat e"t t! *!"ta*t 0ea#t0 *are pr!3e$$ !"a# 3 *0e$t pa " 1!e$ "!t 'pr!6e !r 9!r$e"$ a3ter t0erap/5 3 t !**)r$ 9 t0 1 ap0!re$ $5 3 $0!rt"e$$ !3 (reat0 !**)r$5 !r 3 $e6ere5 per$ $te"t 0ea1a*0e !**)r$. Ca)t !" pat e"t t! 1 $*)$$ e7er* $e re$tr *t !"$ 9 t0 0ea#t0 *are pr!3e$$ !"a# (e3!re e7ert !". E"*!)ra,e pat e"t t! *!'p#/ 9 t0 !t0er "ter6e"t !"$ 3!r 0/perte"$ !" +9e ,0t re1)*t !"5 #!9=$!1 )' 1 et5 $'!4 ", *e$$at !"5 '!1erat !" !3 a#*!0!# *!"$)'pt !"5 re,)#ar e7er* $e5 a"1 $tre$$ 'a"a,e'e"t-. Me1 *at !" *!"tr!#$ ()t 1!e$ "!t *)re 0/perte"$ !". I"$tr)*t pat e"t a"1 3a' #/ " pr!per te*0" .)e 3!r '!" t!r ", 2P. A16 $e pat e"t t! ta4e 2P 9ee4#/ a"1 t! rep!rt $ ," 3 *a"t *0a",e$ t! 0ea#t0 *are pr!3e$$ !"a#. Na'e L p t!r R!)te PO P0ar'a*e)t *a# *#a$$: 0', *!a re1)*ta$e "0 ( t!r$ H!'e C!"*e"trat !" Fre.)e"*/ 1 ta( Da #/ H!$p ta# !r 2!t0 D!$a,e A'!)"t ;< ',

I"1 *at !" A1B)"*t 6e 'a"a,e'e"t !3 pr 'ar/ 0/per*0!#e$ter!#e' a a"1 ' 7e1 1/$# p 1e' a. Pr 'ar/ pre6e"t !" !3 *!r!"ar/ 0eart 1 $ea$e +'/!*ar1 a# "3ar*t !"5 $tr!4e5 a", "a5 a"1 *!r!"ar/ re6a$*)#ar :at !"- " a$/'pt!'at * pat e"t$ 9 t0 "*rea$e1 t!ta# a"1 #!9=1e"$ t/ # p!pr!te " +LDL- *0!#e$ter!# a"1 1e*rea$e1 0 ,0=1e"$ t/ # p!pr!te " +HDL- *0!#e$ter!#. S 1e e33e*t$: CNS: a'"e$ a5 *!"3)$ !"5 1 :: "e$$5 0ea1a*0e5 "$!'" a5 'e'!r/ #!$$5 9ea4"e$$5 EENT: r0 " t $5 Re$p: (r!"*0 t $5 CV: *0e$t pa "5 per p0era# e1e'a5 GI: a(1!' "a# *ra'p$5 *!"$t pat !"5 1 arr0ea5 3#at)$5 0eart()r"5 a#tere1 ta$te5 1r),= "1)*e1 0epat t $5 1/$pep$ a5 D # 6er e":/'e$5 "a)$ea5 pa"*reat t $5 E"1!: 0/per,#/*e' a5 GU: ere*t #e 1/$3)"*t !"5 Der': ra$0e$5 pr)r t)$5 MS: RHA2DOMYOLYSIS5 art0ra#, a5 art0r t $5 '')"e='e1 ate1 "e*r!t : ", '/!pat0/5 '/a#, a5 '/!$ t $5 M $*: HYPERSENSITIVITY REACTIONS INCLUDING ANGIONEUROTIC EDEMA N)r$ ", *!"$ 1erat !"$: I"$tr)*t pat e"t t! ta4e 'e1 *at !" a$ 1 re*te1. Ta4e ' $$e1 1!$e$ a$ $!!" a$ re'e'(ere1 '!re t0a" 12 0r$ $ "*e ' $$e1 1!$e8 !' t a"1 ta4e "e7t $*0e1)#e1 1!$e. D! "!t 1!)(#e )p !" ' $$e1 1!$e$. A16 $e pat e"t t! a6! 1 1r "4 ", '!re t0a" !"e .)art !3 ,rape3r) t B) *e per 1a/ 1)r ", t0erap/. Me1 *at !" 0e#p$ *!"tr!# ()t 1!e$ "!t *)re e#e6ate1 $er)' *0!#e$ter!# #e6e#$. A16 $e pat e"t t0at t0 $ 'e1 *at !" $0!)#1 (e )$e1 " *!"B)"*t !" 9 t0 1 et re$tr *t !"$ +3at5 *0!#e$ter!#5 *ar(!0/1rate$5 a#*!0!#-5 e7er* $e5 a"1 *e$$at !" !3 $'!4 ",. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 )"e7p#a "e1 ')$*#e pa "5 te"1er"e$$5 !r 9ea4"e$$ !**)r$5 e$pe* a##/ 3 a**!'pa" e1 (/ 3e6er !r 'a#a $e. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e" a"1 *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ "e9 'e1 *at !"$. A16 $e pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 'e1 *at !" re, 'e" pr !r t! treat'e"t !r $)r,er/. I"$tr)*t 3e'a#e pat e"t$ t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# pr!'pt#/ 3 pre,"a"*/ $ p#a""e1 !r $)$pe*te15 !r 3 (rea$t3ee1 ",. E'p0a$ :e t0e 'p!rta"*e !3 3!##!9=)p e7a'$ t! 1eter' "e e33e*t 6e"e$$ a"1 t! '!" t!r 3!r $ 1e e33e*t$. Na'e: Met!pr!#!# C!"*e"trat !" D!$a,e A'!)"t 1&< ', R!)te: PO P0ar'a*e)t *a# *#a$$: 2eta (#!*4er H!'e Fre.)e"*/ 2 D H!$p ta# !r 2!t0

I"1 *at !": H/perte"$ !". A", "a pe*t!r $. Pre6e"t !" !3 MI a"1 1e*rea$e1 '!rta# t/ " pat e"t$ 9 t0 re*e"t MI. Ma"a,e'e"t !3 $ta(#e5 $/'pt!'at * +*#a$$ II !r III- 0eart 3a #)re 1)e t! $*0e' *5 0/perte"$ 6e !r *ar1 !'/!pat0* !r , " +'a/ (e )$e1 9 t0 ACE "0 ( t!r$5 1 )ret *$ a"1/!r 1 ,!7 "8 T!pr!# EL !"#/-. S 1e e33e*t$: CNS: 3at ,)e5 9ea4"e$$5 a"7 et/5 1epre$$ !"5 1 :: "e$$5 1r!9$ "e$$5 "$!'" a5 'e'!r/ #!$$5 'e"ta# $tat)$ *0a",e$5 "er6!)$"e$$5 " ,0t'are$ EENT: (#)rre1 6 $ !"5 $t)33/ "!$e5 Re$p: (r!"*0!$pa$'5 90ee: ",5 CV: 2RADYCARDIA5 HF5 PULMONARY EDEMA5 0/p!te"$ !"5 per p0era# 6a$!*!"$tr *t !"5 GI: *!"$t pat !"5 1 arr0ea5 1r),= "1)*e1 0epat t $5 1r/ '!)t05 3#at)#e"*e5 ,a$tr * pa "5 0eart()r"5 D # 6er e":/'e$5 "a)$ea5 6!' t ",5 GU: ere*t #e 1/$3)"*t !"5 F # ( 1!5 )r "ar/ 3re.)e"*/5 Der': ra$0e$5 E"1!: 0/per,#/*e' a5 0/p!,#/*e' a5 MS: art0ra#, a5 (a*4 pa "5 B! "t pa "5 M $*: 1r),= "1)*e1 #)p)$ $/"1r!'e N)r$ ", *!"$ 1erat !"$: I"$tr)*t pat e"t t! ta4e 'e1 *at !" a$ 1 re*te15 at t0e $a'e t 'e ea*0 1a/5 e6e" 3 3ee# ", 9e##8 1! "!t $4 p !r 1!)(#e )p !" ' $$e1 1!$e$. Ta4e ' $$e1 1!$e$ a$ $!!" a$ p!$$ (#e )p t! A 0r (e3!re "e7t 1!$e. A(r)pt 9 t01ra9a# 'a/ pre* p tate # 3e=t0reate" ", arr0/t0' a$5 0/perte"$ !"5 !r '/!*ar1 a# $*0e' a. Tea*0 pat e"t a"1 3a' #/ 0!9 t! *0e*4 p)#$e 1a #/ a"1 2P ( 9ee4#/ a"1 t! rep!rt $ ," 3 *a"t *0a",e$ t! 0ea#t0 *are pr!3e$$ !"a#. Ma/ *a)$e 1r!9$ "e$$. Ca)t !" pat e"t t! a6! 1 1r 6 ", !r !t0er a*t 6 t e$ t0at re.) re a#ert"e$$ )"t # re$p!"$e t! t0e 1r), $ 4"!9". A16 $e pat e"t t! *0a",e p!$ t !"$ $#!9#/ t! ' " ' :e !rt0!$tat * 0/p!te"$ !". Ca)t !" pat e"t t0at t0 $ 'e1 *at !" 'a/ "*rea$e $e"$ t 6 t/ t! *!#1.I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e" a"1 t! *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ R75 OTC5 !r 0er(a# pr!1)*t$5 e$pe* a##/ *!#1 preparat !"$5 *!"*)rre"t#/ 9 t0 t0 $ 'e1 *at !". Pat e"t$ !" a"t 0/perte"$ 6e t0erap/ $0!)#1 a#$! a6! 1 e7*e$$ 6e a'!)"t$ !3 *!33ee5 tea5 a"1 *!#a. D a(et *$ $0!)#1 *#!$e#/ '!" t!r (#!!1 ,#)*!$e5 e$pe* a##/ 3 9ea4"e$$5 'a#a $e5 rr ta( # t/5 !r 3at ,)e !**)r$. Me1 *at !" 1!e$ "!t (#!*4 $9eat ", a$ a $ ," !3 0/p!,#/*e' a. A16 $e pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 $#!9 p)#$e5 1 33 *)#t/ (reat0 ",5 90ee: ",5 *!#1 0a"1$ a"1 3eet5 1 :: "e$$5 # ,0t=0ea1e1"e$$5 *!"3)$ !"5 1epre$$ !"5 ra$05 3e6er5 $!re t0r!at5 )")$)a# (#ee1 ",5 !r (r) $ ", !**)r$. I"$tr)*t pat e"t t! "3!r' 0ea#t0 *are pr!3e$$ !"a# !3 'e1 *at !" re, 'e" (e3!re treat'e"t !r $)r,er/. A16 $e pat e"t t! *arr/ 1e"t 3 *at !" 1e$*r ( ", 1 $ea$e pr!*e$$ a"1 'e1 *at !" re, 'e" at a## t 'e$. H/perte"$ !": Re "3!r*e t0e "ee1 t! *!"t ")e a11 t !"a# t0erap e$ 3!r 0/perte"$ !" +9e ,0t #!$$5 $!1 )' re$tr *t !"5 $tre$$ re1)*t !"5 re,)#ar e7er* $e5 '!1erat !" !3 a#*!0!# *!"$)'pt !"5 a"1 $'!4 ", *e$$at !"-. Me1 *at !" *!"tr!#$ ()t 1!e$ "!t *)re 0/perte"$ !". Na'e Pep* 1 R!)te PO P0ar'a*e)t *a# *#a$$ 0 $ta' "e 02 a"ta,!" $t$ H!'e C!"*e"trat !" Fre.)e"*/ Da #/ H!$p ta# !r 2!t0 D!$a,e A'!)"t 2<',

I"1 *at !" S0!rt=ter' treat'e"t !3 a*t 6e 1)!1e"a# )#*er$ a"1 (e" ," ,a$tr * )#*er$. Ma "te"a"*e t0erap/ 3!r 1)!1e"a# )#*er$ a3ter 0ea# ", !3 a*t 6e )#*er+$-. Ma"a,e'e"t !3 ,a$tr!e$!p0a,ea# re3#)7 1 $ea$e +GERD-. Treat'e"t !3 0eart()r"5 a* 1 "1 ,e$t !"5 a"1 $!)r $t!'a*0 +OTC )$e-. Ma"a,e'e"t !3 ,a$tr * 0/per$e*ret!r/ $tate$ +%!## ",er=E## $!" $/"1r!'e-. Pre6e"t !" a"1 treat'e"t !3 $tre$$= "1)*e1 )pper GI (#ee1 ", " *r t *a##/ ## pat e"t$. S 1e e33e*t$: CNS: *!"3)$ !"5 1 :: "e$$5 1r!9$ "e$$5 0a##)* "at !"$5 0ea1a*0e5 CV: ARRHYTHMIAS5 GI: *!"$t pat !"5 1 arr0ea5 "a)$ea5 GU: F $per' *!)"t5 ere*t #e 1/$3)"*t !"5 E"1!: ,/"e*!'a$t a5 He'at: AGRANULOCYTOSIS5 APLASTIC ANEMIA5 a"e' a5 "e)tr!pe" a5 t0r!'(!*/t!pe" a5 L!*a#: pa " at IM $ te5 M $*: 0/per$e"$ 6 t/ rea*t !"$ N)r$ ", *!"$ 1erat !"$: I"$tr)*t pat e"t t! ta4e 'e1 *at !" a$ 1 re*te1 3!r t0e 3)## *!)r$e !3 t0erap/5 e6e" 3 3ee# ", (etter. Ta4e ' $$e1 1!$e$ a$ $!!" a$ re'e'(ere1 ()t "!t 3 a#'!$t t 'e 3!r "e7t 1!$e. D! "!t 1!)(#e 1!$e$. A16 $e pat e"t$ ta4 ", OTC preparat !"$ "!t t! ta4e t0e 'a7 ')' 1!$e *!"t ")!)$#/ 3!r '!re t0a" 2 94 9 t0!)t *!"$)#t ", 0ea#t0 *are pr!3e$$ !"a#. N!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 1 33 *)#t/ $9a##!9 ", !**)r$ !r a(1!' "a# pa " per$ $t$. I"3!r' pat e"t t0at $'!4 ", "ter3ere$ 9 t0 t0e a*t !" !3 0 $ta' "e a"ta,!" $t$. E"*!)ra,e pat e"t t! .) t $'!4 ", !r at #ea$t "!t t! $'!4e a3ter #a$t 1!$e !3 t0e 1a/. Ma/ *a)$e 1r!9$ "e$$ !r 1 :: "e$$. Ca)t !" pat e"t t! a6! 1 1r 6 ", !r !t0er a*t 6 t e$ re.) r ", a#ert"e$$ )"t # re$p!"$e t! t0e 1r), $ 4"!9". A16 $e pat e"t t! a6! 1 a#*!0!#5 pr!1)*t$ *!"ta " ", a$p r " !r NSAID$5 a"1 3!!1$ t0at 'a/ *a)$e a" "*rea$e " GI rr tat !". I"3!r' pat e"t t0at "*rea$e1 3#) 1 a"1 3 (er "ta4e a"1 e7er* $e 'a/ ' " ' :e *!"$t pat !". A16 $e pat e"t t! rep!rt !"$et !3 (#a*45 tarr/ $t!!#$8 3e6er8 $!re t0r!at8 1 arr0ea8 1 :: "e$$8 ra$08 *!"3)$ !"8 !r 0a##)* "at !"$ t! 0ea#t0 *are pr!3e$$ !"a# pr!'pt#/. M!" t!r C2C 9 t0 1 33ere"t a# per !1 *a##/ 1)r ", t0erap/. A$$e$$ 3!r ep ,a$tr * !r a(1!' "a# pa " a"1 3ra"4 !r !**)#t (#!!1 " t0e $t!!#5 e'e$ $5 !r ,a$tr * a$p rate. Ger : A$$e$$ e#1er#/ a"1 1e( # tate1 pat e"t$ r!)t "e#/ 3!r *!"3)$ !". Rep!rt pr!'pt#/.

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S 1e e33e*t$: CNS: (#)rre1 6 $ !"5 1 :: "e$$5 0ea1a*0e5 6ert ,!5 EENT: 0ear ", #!$$5 t "" t)$5 CV: 0/p!te"$ !"5 GI: a"!re7 a5 *!"$t pat !"5 1 arr0ea5 1r/ '!)t05 1/$pep$ a5 D # 6er e":/'e$5 "a)$ea5 pa"*reat t $5 6!' t ",5 GU: D 2UN5 e7*e$$ 6e )r "at !"5 "ep0r!*a#* "!$ $5 Der': ERYTHEMA MULTIFORME5 STEVENS= GOHNSON SYNDROME5 TOEIC EPIDERMAL NECROLYSIS5 p0!t!$e"$ t 6 t/5 pr)r t $5 ra$05 )rt *ar a#5 E"1!: 0/per*0!#e$ter!#e' a5 0/per,#/*e' a5 0/pertr ,#/*er 1e' a5 0/per)r *e' a5 F a"1 E: 1e0/1rat !"5 0/p!*a#*e' a5 0/p!*0#!re' a5 0/p!4a#e' a5 0/p!'a,"e$e' a5 0/p!"atre' a5 0/p!6!#e' a5 'eta(!# * a#4a#!$ $5 He'at: APLASTIC ANEMIA5 AGRANULOCYTOSIS5 0e'!#/t * a"e' a5 #e)4!pe" a5 t0r!'(!*/t!pe" a5 MS: ')$*#e *ra'p$5 Ne)r!: pare$t0e$ a5 M $*: 3e6er. N)r$ ", *!"$ 1erat !"$: I"$tr)*t pat e"t t! ta4e 3)r!$e' 1e a$ 1 re*te1. Ta4e ' $$e1 1!$e$ a$ $!!" a$ p!$$ (#e8 1! "!t 1!)(#e 1!$e$. Ca)t !" pat e"t t! *0a",e p!$ t !"$ $#!9#/ t! ' " ' :e !rt0!$tat * 0/p!te"$ !". Ca)t !" pat e"t t0at t0e )$e !3 a#*!0!#5 e7er* $e 1)r ", 0!t 9eat0er5 !r $ta"1 ", 3!r #!", per !1$ 1)r ", t0erap/ 'a/ e"0a"*e !rt0!$tat * 0/p!te"$ !". I"$tr)*t pat e"t t! *!"$)#t 0ea#t0 *are pr!3e$$ !"a# re,ar1 ", a 1 et 0 ,0 " p!ta$$ )' +$ee 3!!1 $!)r*e$ 3!r $pe* 3 * ")tr e"t$-. A16 $e pat e"t t! *!"ta*t 0ea#t0 *are pr!3e$$ !"a# !3 9e ,0t ,a " '!re t0a" 3 #($ " 1 1a/. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e" a"1 t! *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ OTC 'e1 *at !"$ *!"*)rre"t#/ 9 t0 t0 $ t0erap/. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 'e1 *at !" re, 'e" (e3!re treat'e"t !r $)r,er/. Ca)t !" pat e"t t! )$e $)"$*ree" a"1 pr!te*t 6e *#!t0 ", t! pre6e"t p0!t!$e"$ t 6 t/ rea*t !"$. A16 $e pat e"t t! *!"ta*t 0ea#t0 *are pr!3e$$ !"a# ''e1 ate#/ 3 ra$05 ')$*#e 9ea4"e$$5 *ra'p$5 "a)$ea5 1 :: "e$$5 ")'("e$$5 !r t ",# ", !3 e7tre' t e$ !**)r$. A16 $e 1 a(et * pat e"t$ t! '!" t!r (#!!1 ,#)*!$e *#!$e#/8 'a/ *a)$e "*rea$e1 (#!!1 ,#)*!$e #e6e#$. E'p0a$ :e t0e 'p!rta"*e !3 r!)t "e 3!##!9=)p e7a' "at !"$. Ger : Ca)t !" !#1er pat e"t$ !r t0e r *are, 6er$ a(!)t "*rea$e1 r $4 3!r 3a##$. S),,e$t $trate, e$ 3!r 3a## pre6e"t !". H/perte"$ !": A16 $e pat e"t$ !" a"t 0/perte"$ 6e re, 'e" t! *!"t ")e ta4 ", 'e1 *at !" e6e" 3 3ee# ", (etter. F)r!$e' 1e *!"tr!#$ ()t 1!e$ "!t *)re 0/perte"$ !". Re "3!r*e t0e "ee1 t! *!"t ")e a11 t !"a# t0erap e$ 3!r 0/perte"$ !" +9e ,0t #!$$5 e7er* $e5 re$tr *te1 $!1 )' "ta4e5 $tre$$ re1)*t !"5 re,)#ar e7er* $e5 '!1erat !" !3 a#*!0!# *!"$)'pt !"5 *e$$at !" !3 $'!4 ",-. M!" t!r e#e*tr!#/te$5 re"a# a"1 0epat * 3)"*t !"5 $er)' ,#)*!$e5 a"1 )r * a* 1 #e6e#$ (e3!re a"1 per !1 *a##/ t0r!),0!)t t0erap/. C!''!"#/ F $er)' p!ta$$ )'. Ma/ *a)$e F $er)' $!1 )'5 *a#* )'5 a"1 'a,"e$ )' *!"*e"trat !"$. Ma/ a#$! *a)$e D 2UN5 $er)' ,#)*!$e5 *reat " "e5 a"1 )r * a* 1 #e6e#$. A$$e$$ pat e"t 3!r t "" t)$ a"1 0ear ", #!$$. A)1 !'etr/ $ re*!''e"1e1 3!r pat e"t$ re*e 6 ", pr!#!",e1 0 ,0=1!$e IV t0erap/. Hear ", #!$$ $ '!$t *!''!" a3ter rap 1 !r 0 ,0=1!$e IV a1' " $trat !" " pat e"t$ 9 t0 1e*rea$e1 re"a# 3)"*t !" !r t0!$e ta4 ", !t0er !t!t!7 * 1r),$. D )ret * )$e $ a$$!* ate1 9 t0 "*rea$e1 r $4 3!r 3a##$ " !#1er a1)#t$. A$$e$$ 3a##$ r $4 a"1 'p#e'e"t 3a## pre6e"t !" $trate, e$. A$$e$$ 3#) 1 $tat)$. M!" t!r 1a #/ 9e ,0t5 "ta4e a"1 !)tp)t rat !$5 a'!)"t a"1 #!*at !" !3 e1e'a5 #)", $!)"1$5 $4 " t)r,!r5 a"1 ')*!)$ 'e'(ra"e$. N!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 t0 r$t5 1r/ '!)t05 #et0ar,/5 9ea4"e$$5 0/p!te"$ !"5 !r !# ,)r a !**)r$. Na'e Va#$arta" R!)te PO P0ar'a*e)t *a# *#a$$ a", !te"$ " II re*ept!r a"ta,!" $t$ H!'e C!"*e"trat !" Fre.)e"*/ 2 ta($ Da #/ H!$p ta# !r 2!t0 D!$a,e A'!)"t 32<',

I"1 *at !": A#!"e !r 9 t0 !t0er a,e"t$ " t0e 'a"a,e'e"t !3 0/perte"$ !". Treat'e"t !3 0eart 3a #)re +Ne9 Y!r4 Heart A$$!* at !" *#a$$ II=IV-. Re1)*t !" !3 r $4 !3 1eat0 3r!' *ar1 !6a$*)#ar *a)$e$ " pat e"t$ 9 t0 #e3t 6e"tr *)#ar $/$t!# * 1/$3)"*t !" 3!##!9 ", '/!*ar1 a# "3ar*t !". S 1e e33e*t$: CNS: 1 :: "e$$5 3at ,)e5 0ea1a*0e5 CV: e1e'a5 0/p!te"$ !"5 EENT: p0ar/", t $5 r0 " t $5 $ ")$ t $5 F a"1 E: 0/per4a#e' a5 GI: a(1!' "a# pa "5 1 arr0ea5 "a)$ea5 GU: 'pa re1 re"a# 3)"*t !"5 MS: art0ra#, a5 (a*4 pa "5 M $*: ANGIOEDEMA. N)r$ ", *!"$ 1erat !"$: M!" t!r re"a# 3)"*t !". Ma/ *a)$e "*rea$e " 2UN a"1 $er)' *reat " "e. A$$e$$ 2P +#/ ",5 $ tt ",5 $ta"1 ",- a"1 p)#$e 3re.)e"t#/ 1)r ", " t a# 1!$a,e a1B)$t'e"t a"1 per !1 *a##/ t0r!),0!)t t0erap/. N!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 $ ," 3 *a"t *0a",e$. A$$e$$ pat e"t$ 3!r $ ,"$ !3 a", !e1e'a +1/$p"ea5 3a* a# $9e## ",-. M!" t!r 1a #/ 9e ,0t a"1 a$$e$$ pat e"t r!)t "e#/ 3!r re$!#)t !" !3 3#) 1 !6er#!a1 +per p0era# e1e'a5 ra#e$/*ra*4#e$5 1/$p"ea5 9e ,0t ,a "5 B),)#ar 6e"!)$ 1 $te"t !"-. Ca)t !" pat e"t t! a6! 1 $a#t $)($t t)te$ *!"ta " ", p!ta$$ )' !r 3!!1$ *!"ta " ", 0 ,0 #e6e#$ !3 p!ta$$ )' !r $!1 )' )"#e$$ 1 re*te1 (/ 0ea#t0 *are pr!3e$$ !"a#. Ca)t !" pat e"t t! a6! 1 $)11e" p!$ t !" *0a",e$ t! 1e*rea$e !rt0!$tat * 0/p!te"$ !". U$e !3 a#*!0!#5 $ta"1 ", 3!r #!", per !1$5 e7er* $ ",5 a"1 0!t 9eat0er 'a/ "*rea$e !rt0!$tat * 0/p!te"$ !". Ma/ *a)$e 1 :: "e$$. Ca)t !" pat e"t t! a6! 1 1r 6 ", !r !t0er a*t 6 t e$ re.) r ", a#ert"e$$ )"t # re$p!"$e t! 'e1 *at !" $ 4"!9". I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# 3 $9e## ", !3 3a*e5 e/e$5 # p$5 !r t!",)e !r 3 1 33 *)#t/ $9a##!9 ", !r (reat0 ", !**)r. E"*!)ra,e pat e"t t! *!'p#/ 9 t0 a11 t !"a# "ter6e"t !"$ 3!r 0/perte"$ !" +9e ,0t re1)*t !"5 #!9=$!1 )' 1 et5 1 $*!"t ")at !" !3 $'!4 ",5 '!1erat !" !3 a#*!0!# *!"$)'pt !"5 re,)#ar e7er* $e5 $tre$$ 'a"a,e'e"t-. Me1 *at !" *!"tr!#$ ()t 1!e$ "!t *)re 0/perte"$ !". I"$tr)*t pat e"t a"1 3a' #/ !" pr!per te*0" .)e 3!r '!" t!r ", 2P. A16 $e t0e' t! *0e*4 2P at #ea$t 9ee4#/ a"1 t! rep!rt $ ," 3 *a"t *0a",e$. Na'e A*eta' "!p0e" R!)te PO P0ar'a*e)t *a# *#a$$ A"t =p/ret */N!"=!p ! 1 a"a#,e$ * I"1 *at !" Treat'e"t !3 ' #1 pa " a"1 3e6er S 1e e33e*t$ A, tat !"5 a"7 et/5 0ea1a*0e5 3at ,)e5 "$!'" a5 ate#e*ta$ $5 1/$p"ea5 0/perte"$ !"5 0/p!te"$ !"5 0epat!t!7 * t/5 *!"$t pat !"5 "*rea$e1 # 6er e":/'e$5 "a)$ea5 6!' t ",5 0/p!4a#e' a5 re"a# 3a #)re5 "e)tr!pe" a5 pa"*/t!pe" a5 ')$*#e $pa$'$5 tr $')$5 ra$05 a"1 )rt *ar a. N)r$ ", *!"$ 1erat !"$ )$e *a)t !)$#/ " pat e"t$ 9 t0 0epat */re"a# 1 $ea$e5 a#*!0!# *$ a"1 'a#"!)r $0e1 pat e"t$. D! "!t 1r "4 90 #e ta4 ", a*eta' "!p0e" re,)#ar#/. A$$e$$ t/pe5 #!*at !"5 a"1 "te"$ t/ !3 pa " pr !r t! a"1 3<@?< ' " 3!##!9 ", a1' " $trat !". A$$e$$ 3e6er8 "!te pre$e"*e !3 a$$!* ate1 $ ,"$ +1 ap0!re$ $5 ta*0/*ar1 a5 a"1 'a#a $e-. D! "!t ta4e '!re t0a" 35<<< ', " !"e 2; 0r per !1. Na'e Sertra# "e R!)te PO P0ar'a*e)t *a# *#a$$ $e#e*t 6e $er!t!" " re)pta4e "0 ( t!r$ $$r $ H!'e C!"*e"trat !" Fre.)e"*/ 1 ta( 1a #/ H!$p ta# !r 2!t0 D!$a,e A'!)"t &<', H!'e C!"*e"trat !" Fre.)e"*/ .;0/ PRN H!$p ta# !r 2!t0 D!$a,e A'!)"t 32& ',

I"1 *at !": MaB!r 1epre$$ 6e 1 $!r1er. Pa" * 1 $!r1er. O($e$$ 6e=*!'p)#$ 6e 1 $!r1er +OCD-. P!$t=tra)'at * $tre$$ 1 $!r1er +PTSD-. S!* a# a"7 et/ 1 $!r1er +$!* a# p0!( a-. Pre'e"$tr)a# 1/$p0!r * 1 $!r1er +PMDD-. S 1e e33e*t$: CNS: NEUROLEPTIC MALIGNANT SYNDROME5 SUICIDAL THOUGHTS5 1 :: "e$$5 1r!9$ "e$$5 3at ,)e5 0ea1a*0e5 "$!'" a5 a, tat !"5 a"7 et/5 *!"3)$ !"5 e'!t !"a# #a( # t/5 'pa re1 *!"*e"trat !"5 'a" * rea*t !"5 "er6!)$"e$$5 9ea4"e$$5 /a9" ",5 EENT: p0ar/", t $5 r0 " t $5 t "" t)$5 6 $)a# a("!r'a# t e$5 CV: *0e$t pa "5 pa#p tat !"$5 GI: 1 arr0ea5 1r/ '!)t05 "a)$ea5 a(1!' "a# pa "5 a#tere1 ta$te5 a"!re7 a5 *!"$t pat !"5 1/$pep$ a5 3#at)#e"*e5 D appet te5 6!' t ",5 GU: $e7)a# 1/$3)"*t !"5 'e"$tr)a# 1 $!r1er$5 )r "ar/ 1 $!r1er$5 )r "ar/ 3re.)e"*/5 Der': D $9eat ",5 0!t 3#a$0e$5 ra$05 E"1!: 1 a(ete$5 F

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

a"1 E: 0/p!"atre' a5 MS: (a*4 pa "5 '/a#, a5 Ne)r!: tre'!r5 0/pert!" a5 0/p!e$t0e$ a5 pare$t0e$ a5 t9 t*0 ",5 M $*: SEROTONIN SYNDROME5 3e6er5 t0 r$t N)r$ ", *!"$ 1erat !"$: A$$e$$ 3!r $) * 1a# te"1e"* e$5 e$pe* a##/ 1)r ", ear#/ t0erap/. Re$tr *t a'!)"t !3 1r), a6a #a(#e t! pat e"t. R $4 'a/ (e "*rea$e1 " *0 #1re"5 a1!#e$*e"t$5 a"1 a1)#t$ H2; /r. A3ter $tart ", t0erap/5 *0 #1re"5 a1!#e$*e"t$5 a"1 /!)", a1)#t$ $0!)#1 (e $ee" (/ 0ea#t0 *are pr!3e$$ !"a# at #ea$t 9ee4#/ 3!r ; 945 e6er/ 3 94 3!r "e7t ; 945 a"1 !" a16 *e !3 0ea#t0 *are pr!3e$$ !"a# t0erea3ter. A$$e$$ 3!r $er!t!" " $/"1r!'e +'e"ta# *0a",e$ Ia, tat !"5 0a##)* "at !"$5 *!'aJ5 a)t!"!' * "$ta( # t/ Ita*0/*ar1 a5 #a( #e 2P5 0/pert0er' aJ5 "e)r!')$*)#ar a(errat !"$ I0/per=re3#e7 a5 "*!!r1 "at !"J5 a"1/!r GI $/'pt!'$ I"a)$ea5 6!' t ",5 1 arr0eaJ-5 e$pe* a##/ " pat e"t$ ta4 ", !t0er $er!t!"er, * 1r),$ +SSRI$5 SNRI$5 tr pta"$-. I"$tr)*t pat e"t t! ta4e $ertra# "e a$ 1 re*te1. Ta4e ' $$e1 1!$e$ a$ $!!" a$ p!$$ (#e a"1 ret)r" t! re,)#ar 1!$ ", $*0e1)#e. D! "!t 1!)(#e 1!$e$. Ma/ *a)$e 1r!9$ "e$$ !r 1 :: "e$$. Ca)t !" pat e"t t! a6! 1 1r 6 ", a"1 !t0er a*t 6 t e$ re.) r ", a#ert"e$$ )"t # re$p!"$e t! t0e 1r), $ 4"!9". A16 $e pat e"t5 3a' #/5 a"1 *are, 6er$ t! #!!4 3!r $) * 1a# t/5 e$pe* a##/ 1)r ", ear#/ t0erap/ !r 1!$e *0a",e$. N!t 3/ 0ea#t0 *are pr!3e$$ !"a# ''e1 ate#/ 3 t0!),0t$ a(!)t $) * 1e !r 1/ ",5 atte'pt$ t! *!'' t $) * 1e8 "e9 !r 9!r$e 1epre$$ !" !r a"7 et/8 a, tat !" !r re$t#e$$"e$$8 pa" * atta*4$8 "$!'" a8 "e9 !r 9!r$e rr ta( # t/5 a,,re$$ 6e"e$$5 a*t ", !" 1a",er!)$ 'p)#$e$5 'a" a5 !r !t0er *0a",e$ " '!!1 !r (e0a6 !r !r 3 $/'pt!'$ !3 $er!t!" " $/"1r!'e !**)r. A16 $e pat e"t t! a6! 1 a#*!0!# !r !t0er CNS 1epre$$a"t 1r),$ 1)r ", t0erap/ a"1 t! *!"$)#t 9 t0 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", !t0er 'e1 *at !"$ a"1 t! a6! 1 a#*!0!# !r !t0er CNS 1epre$$a"t 1r),$ 1)r ", t0erap/. I"$tr)*t pat e"t t! "!t 3/ 0ea#t0 *are pr!3e$$ !"a# !3 a## R7 !r OTC 'e1 *at !"$5 6 ta' "$5 !r 0er(a# pr!1)*t$ (e ", ta4e" a"1 *!"$)#t 0ea#t0 *are pr!3e$$ !"a# (e3!re ta4 ", a"/ "e9 'e1 *at !"$. I"3!r' pat e"t t0at 3re.)e"t '!)t0 r "$e$5 ,!!1 !ra# 0/, e"e5 a"1 $),ar#e$$ ,)' !r *a"1/ 'a/ ' " ' :e 1r/ '!)t0. I3 1r/ '!)t0 per$ $t$ 3!r '!re t0a" 2 945 *!"$)#t 0ea#t0 *are pr!3e$$ !"a# re,ar1 ", )$e !3 $a# 6a $)($t t)te. A16 $e pat e"t t! 9ear $)"$*ree" a"1 pr!te*t 6e *#!t0 ", t! pre6e"t p0!t!$e"$ t 6 t/ rea*t !"$. Na'e R!)te P0ar'a*e)t *a# *#a$$ I"1 *at !" S 1e e33e*t$/N)r$ ", *!"$ 1erat !"$ Na'e R!)te P0ar'a*e)t *a# *#a$$ I"1 *at !" S 1e e33e*t$/N)r$ ", *!"$ 1erat !"$ H!'e C!"*e"trat !" Fre.)e"*/ H!$p ta# !r 2!t0 D!$a,e A'!)"t H!'e C!"*e"trat !" Fre.)e"*/ H!$p ta# !r 2!t0 D!$a,e A'!)"t

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

 & NUTRITION: Include ty&e of diet, +0 2$ average home diet, and your nutritional analysis with recommendations.
!iet ordered in hos&ital@ "ardiac !iet &t follows at home@ none +0 2$ average home diet; Breakfast; 8sually instant oatmeal or an a&&le with OG or water. #bout a M cu& of oatmeal and brown sugar (/ts&.'. 1ometimes cereal like fiber / N a cu& of cereal with / cu& skim milk. #nalysis of home diet ("om&are to >y (late and "onsider co)morbidities and cultural considerations'; "ombining the oatmeal (or cereal' and bread from lunch the &atient receives the minimum amount of grains necessary for a women over ?7 for one day; . oC. It would be better for the client to eat whole grain bread instead of refined white bread and ideally ?7O of grains should be whole grain. %his is a great start, and an easy fi4 to switch from white to wheat in order to receive more whole grains. # whole grain &asta or wild brown rice side with dinner would be a great addition and &ut the &atient closer to the recommended daily amount of ? oC. / whole a&&le with oatmeal is an e4cellent start, and &rovides +-. of the amount of fruit necessary for an <+ year old woman. # snack container of fruit cocktail or a&&lesauce with dinner or lunch would su&&ly the remaining necessary amount to meet the recommended / M cu&s of fruit. the fiber contained in fruit can hel& with digestion and hel& lower risks for heart disease, heart attack and stroke. 3ating sandwich meats and a meat o&tion with dinner will easily fulfill the recommended amount of ? oC.s. "hicken is a great choice as it is lean. 1andwich meats may hide a large amount of sodium which can e4acerbate "26 and should be avoided. # great substitution for sandwich meat might be a bean salad for lunch or some sort of bean medley cou&led with low sodium &eanuts as a snack to su&&ly lean, low sodium &rotein. + cu&s of vegetables are recommended daily, if beans were added to lunch, cou&led with a ty&ical / cu& of steamed veggies for dinner, the &atient would reach the $!#. (an fried may not be the healthiest o&tion but &an frying in a small amount of olive oil would be a nice way to add fat-oils to the &atients diet. Better yet, a bean salad driCCled in vinegar and oil, while baking chicken or &ork for dinner would be an e4cellent mi4. Bith &ork and cheese it is im&ortant to watch sodium intake for a "26 &atient.

unch; 1andwich (turkey-ham-roast beef' on white bread with low sodium &retCel sticks and some sort of side like carrots, low sodium chi&s, mi4ed nuts (roasted-salted'.

!inner; 1teamed veggies (/-+ cu&' with cheese, and meat like chicken or &ork, usually &an fried.

1nacks; I dont really snack throughout the day iDuids (include alcohol'; >ostly water, Iced tea or (ubli4 lemonade when not. N? < oC. cu&s a day of liDuid. Bater and tea are great choices as long as the tea stays unsweetened. Increasing the daily amount of fluids the &atient receives will hel& with consti&ation when cou&led with fiber, but the &atient must adhere to any fluid restrictions &rescribed by a &hysician so not to e4acerbate her "26.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

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8se this link for the nutritional analysis by com&aring the &atients +0 2$ average home diet to the recommended &ortions, and use >y (late as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are &rom&ts designed to hel& guide your discussion'
Bho hel&s you when you are ill@ I have friends who check in on me all the time to make sure Im OE. 2ow do you generally co&e with stress@ or Bhat do you do when you are u&set@ Ill go for a walk around our com&le4, or call a friend to talk. Bhen Im u&set I Gust try to not let it bother me, I dont have a lot of time to let things bother meP

$ecent difficulties (6eelings of de&ression, an4iety, being overwhelmed, relationshi&s, friends, social life' Ive been on de&ression drugs for a while, they seem to work, I dont get blue very often anymore, I guess thats why.

K2 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. 2ave you ever felt unsafe in a close relationshi&@ QQQQQQQQQQ9oQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ 2ave you ever been talked down to@QQQQQ9oQQQQQQQQQQ 2ave you ever been hit &unched or sla&&ed@ QQQQQQQQQ9oQQQQQ 2ave you been emotionally or &hysically harmed in other ways by a &erson in a close relationshi& with you@ QQQQQQQQQQQQQQQQQQQQQQ9oQQQQQQQQQQQQQQQQQQQQ If yes, have you sought hel& for this@ QQQQQQQQQQQQQQ9oQQQQQQQQ #re you currently in a safe relationshi&@ 1ingle

; DEVELOPMENTAL CONSIDERATIONS:
3riksons stage of &sychosocial develo&ment;
Inferiority Identity vs. $ole "onfusion-!iffusion %rust vs. >istrust #utonomy vs. !oubt R 1hame Initiative vs. =uilt Industry vs. Intimacy vs. Isolation =enerativity vs. 1elf absor&tion-1tagnation 3go Integrity vs. !es&air

"heck one bo4 and give the te4tbook definition (with citation and reference' of both &arts of 3ricksons develo&mental stage for your &atients age grou&; Older adults need to look back on life and feel a sense of fulfillment. 1uccess at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and des&air. (3riksonLs 1tages of (sychosocial !evelo&ment. +7/.' !escribe the stage your &atient is in and give the characteristics that the &atient e4hibits that led you to your determination;

%his &atient is definitely in the stage of 3go integrity vs. !es&air, and I believe she has accom&lished ego integrity. #s a kindergarten teacher she has hel&ed nurture young minds and given back to the community which can contribute to a sense of fulfillment in life.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

!escribe what im&act of disease-condition or hos&italiCation has had on your &atients develo&mental stage of life;

I dont believe any, she seems very content with her life and this is only a setback that she will be able to ada&t to.

K3 CULTURAL ASSESSMENT:
Bhat do you think is the cause of your illness@ Bad luck I guess, my &arents and my sister both had heart &roblems. Bhat does your illness mean to you@ *ust another obstacle.

K3 SEEUALITY ASSESSMENT: +t0e 3!##!9 ", prompts 'a/ 0e#p t! ,) 1e /!)r 1 $*)$$ !"Consider beginning with: I am asking about your se!ual history in order to obtain information that will screen for possible se!ual health problems, these are usually related to either infection, changes with aging and"or quality of life. #ll of these questions are confidential and protected in your medical record 2ave you ever been se4ually active@ QQQQQQQTesQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ !o you &refer women, men or both genders@ QQQQQQQQQQQQQQ>enQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ #re you aware of ever having a se4ually transmitted infection@ QQQQQQQQQ9oQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ 2ave you or a &artner ever had an abnormal &a& smear@ QQQQQQQQQ9oQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ 2ave you or your &artner received the =ardasil (2(A' vaccination@ QQQQQQQQQQQQQQQQQQQQQQQQQQQQ9oQQQQQQQQQQQQQQQ #re you currently se4ually active@ QQQQQQ9oQQQQQQQQQQQQQQQQQQQQBhen se4ually active, what measures do you take to &revent acDuiring a se4ually transmitted disease or an unintended &regnancy@ QQQQQQQQQQQQQQQQQQQQQQQQQQ9oneQQQQQQQQ 2ow long have you been with your current &artner@ QQQQQQQQQ1ingleQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ 2ave any medical or surgical conditions changed your ability to have se4ual activity@ QQQQQ9oQQQQQQQQQQQQQQQQQQQQQQ !o you have any concerns about se4ual health or how to &revent se4ually transmitted disease or unintended &regnancy@ no

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L1 SPIRITUALITY ASSESSMENT: (including but not limited to the following Duestions'

Bhat im&ortance does religion or s&irituality have in your life@ QQQQQQQ Q=od is very im&ortant to me, I go to church every 1unday. QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ !o your religious beliefs influence your current condition@ QQQQQQQQQQ I believe that this is =ods (lan for me. I may not like it, but its whats been given to me to make something of. QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ

K3 SMOMING5 CHEMICAL USE5 OCCUPATIONAL/ENVIRONMENTAL EEPOSURES:

/. !oes the &atient currently, or has he-she ever smoked or used chewing tobacco@ If so, what@ 2ow much@(s&ecify daily amount' Tes 9o 6or how many years@ 5 years
(age thru '

(ack Tears; !oes anyone in the &atients household smoke tobacco@ If so, what, and how much@

If a&&licable, when did the &atient Duit@ 2as the &atient ever tried to Duit@

+. !oes the &atient drink alcohol or has he-she ever drank alcohol@ Tes 9o Bhat@ 2ow much@ (give s&ecific volume' (atient !enies alcohol useUI didnt like the way it made me feel when I tried it. If a&&licable, when did the &atient Duit@

6or how many years@

(age thru '

.. 2as the &atient ever used street drugs such as mariGuana, cocaine, heroin, or other@ Tes 9o If so, what@ 2ow much@ 6or how many years@
(age thru '

Is the &atient currently using these drugs@ Tes 9o

If not, when did he-she Duit@

0. 2ave you ever, or are you currently e4&osed to any occu&ational or environmental 2aCards-$isks 9one that I can think of. >aybe the older schools had asbestos, but I dont remember hearing about that.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

//

 1< REVIEN OF SYSTEMS

Ge"era# C!"$t t)t !"
$ecent weight loss or gain

Ga$tr! "te$t "a#

9ausea, vomiting, or diarrhea "onsti&ation Irritable Bowel =3$! "holecystitis Indigestion =astritis - 8lcers 2emorrhoids Blood in the stool Tellow Gaundice 2e&atitis (ancreatitis "olitis !iverticulitis #&&endicitis #bdominal #bscess ast colonosco&y@ Other;

I'')"!#!, *
"hills with severe shaking 9ight sweats 6ever 2IA or #I!1 u&us $heumatoid #rthritis 1arcoidosis %umor ife threatening allergic reaction 3nlarged lym&h nodes Other;

I"te,)'e"tar/
"hanges in a&&earance of skin (roblems with nails !andruff (soriasis 2ives or rashes 1kin infections 8se of sunscreen 1(6; Bathing routine; Other; 1Duamous cell carcinoma

HEENT
!ifficulty seeing "ataracts or =laucoma !ifficulty hearing 3ar infections 1inus &ain or infections 9ose bleeds (ost)nasal dri& Oral-&haryngeal infection !ental &roblems $outine brushing of teeth $outine dentist visits Aision screening Other; (atient has dentures

He'at!#!, */O"*!#!, *
#nemia Bleeds easily Bruises easily "ancer Blood %ransfusions Blood ty&e if known; Other;

Ge" t!)r "ar/

nocturia dysuria hematuria &olyuria kidney stones 9ormal freDuency of urination; Bladder or kidney infections +-day /-year

4-day

Meta(!# */E"1!*r "e

!iabetes %y&e; 2y&othyroid -2y&erthyroid Intolerance to hot or cold Osteo&orosis Other;

P)#'!"ar/
!ifficulty Breathing "ough ) dry or &roductive #sthma Bronchitis 3m&hysema (neumonia %uberculosis 3nvironmental allergies last "5$@ +-/7-/0 Other;

Ce"tra# Ner6!)$ S/$te'

NOMEN ONLY Infection of the female genitalia >onthly self breast e4am 6reDuency of &a&-&elvic e4am !ate of last gyn e4am@ (t doesnt remember menstrual cycle regular irregular menarche age@ meno&ause age K7 !ate of last >ammogram R$esult; !oesnt remember !ate of !35# Bone !ensity R $esult; MEN ONLY Infection of male genitalia-&rostate@ 6reDuency of &rostate e4am@ !ate of last &rostate e4am@ B(2 8rinary $etention "A# !iCCiness 1evere 2eadaches >igraines 1eiCures %icks or %remors 3nce&halitis >eningitis Other;%I#

Car1 !6a$*)#ar
2y&ertension 2y&erli&idemia "hest &ain - #ngina >yocardial Infarction "#!-(A! "26 >urmur %hrombus $heumatic 6ever >yocarditis #rrhythmias ast 3E= screening, when@

Me"ta# I##"e$$
!e&ression 1chiCo&hrenia #n4iety Bi&olar Other;

M)$*)#!$4e#eta#
InGuries or 6ractures Beakness (ain =out Osteomyelitis #rthritis

C0 #10!!1 D $ea$e$
>easles >um&s (olio 1carlet 6ever "hicken (o4 V?

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

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Other; ###

Other;

Other;

REVIEN OF SYSTEMS NARRATIVE

Ge"era# C!"$t t)t !" +OLDCART a"/t0 ", *0e*4e1 a(!6e-: (atient is unable to account for recent weight loss, feels she has been eating what is considered normal for her. #lbumin levels from the initial blood draw show lowered values and this may reflect under nutrition.
(ts &erce&tion of health; (atient feels they are in good health considering. (atient believes that they will be able to ada&t to this new diagnosis after these acute e4acerbations are treated.

Integumentary; 2339%; (ulmonary; "ardiovascular; =I; =8; Bomen->en Only; >usculoskeletal; Immunologic; 2ematologic-Oncologic; >etabolic-3ndocrine; "entral 9ervous 1ystem; >ental Illness; "hildhood !iseases;

Is there any &roblem that is not mentioned that your &atient sought medical attention for with anyone@ 9o

#ny other Duestions or comments that your &atient would like you to know@ 9o

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

/.

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

/0

L1< PHYSICAL EEAMINATION:(!escribe abnormal assessment below non checked bo4es'

=eneral 1urvey; (atient is a, 2eight; K0 amiable, cheerful and bright (ulse; ?S <+ year old female with a history of hy&ertension, atrial fibrillation, %I#, and hy&erli&idemia who is now &resenting with "26. (atient a&&ears her stated age and a&art from slight memory loss seems very alert. (atient e4hibits a&&ro&riate hygiene. (atient is alert and orientated, making Gokes and conversation when awake. (atient com&lains of slee& disturbances last night due to coughing and dys&nea and has s&ent a maGority of the day slee&ing. %em&erature; (route taken@' $es&irations; /S S<.0 oral 1&O+ SKO Beight; /<S B>I; .+.0F (ain; (include rating R location' .-/7UgeneraliCed body &ain from O#. Blood (ressure; /F7-FF $ forearm
(include location'

Is the &atient on $oom #ir or O+; $# with + O+ ($9 9asal

"annula.

Overall #&&earance; I!ress-grooming-&hysical handica&s-eye contactJ clean, hair combed, dress a&&ro&riate for setting and tem&erature, maintains eye contact, no obvious handica&s Overall Behavior; Ie.g.; a&&ro&riate-restless-odd mannerisms-agitated-lethargic-otherJ awake, calm, rela4ed, interacts well with others, Gudgment intact 1&eech; Ie.g.; clear-mumbles -ra&id -slurred-silent-otherJ (atients dentures can make s&eaking difficult at times. clear, cris& diction >ood and #ffect; &leasant coo&erative cheerful a&athetic biCarre agitated an4ious tearful Other; I"te,)'e"tar/ 1kin is warm, dry, and intact 1kin turgor elastic 9o rashes, lesions, or deformities 9ails without clubbing "a&illary refill V . seconds 2air evenly distributed, clean, without vermin (atient has a venous stasis ulcer on 3 ( ankle'. talkative withdrawn Duiet boisterous aggressive hostile flat loud

(eri&heral IA site %y&e; ++= no redness, edema, or discharge 6luids infusing@ no yes ) what@ (eri&heral IA site %y&e; no redness, edema, or discharge

ocation; ocation;

forearm !ate inserted;

!ate inserted;

+-+7-/0

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

/?

6luids infusing@ no yes ) what@ "entral access device %y&e; 6luids infusing@ no yes ) what@

ocation;

!ate inserted;

HEENT: 6acial features symmetric 9o &ain in sinus region 9o &ain, clicking of %>* %rachea midline %hyroid not enlarged 9o &al&able lym&h nodes sclera white and conGunctiva clearH without discharge 3yebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness (3$$ # &u&il siCe 0 - 0 mm (eri&heral vision intact 3O> intact through K cardinal fields without nystagmus 3ars symmetric without lesions or discharge Bhis&er test heard; right ear) K inches R left ear) K inches 9ose without lesions or discharge i&s, buccal mucosa, floor of mouth, R tongue &ink R moist without lesions !entition; (atient is able to chew-swallow with no issues. "omments;

8niversity of 1outh 6lorida "ollege of 9ursing : $evision #ugust +7/.

/K

P)#'!"ar//T0!ra7:

$es&irations regular and unlabored %ransverse to #( ratio +;/ "hest e4&ansion symmetric ungs clear to auscultation in all fields without adventitious sounds " : "lear (ercussion resonant throughout all lung fields, dull towards &osterior bases
B2 : BheeCes "$ ) "rackles $2 : $honchi ! : !iminished 1 : 1tridor #b ) #bsent

1&utum &roduction; thick thin #mount; scant small moderate large "olor; white &ale yellow yellow dark yellow green gray light tan brown red (atient had e4&iratory wheeCes bilaterally in lower lobes. "rackles and $honchi &resent in u&&er and lower lobes.

Car1 !6a$*)#ar: 9o lifts, heaves, or thrills (>I felt at; ?th I"1 >" 2eart sounds; 1/ 1+ $egular Irregular 9o murmurs, clicks, or adventitious heart sounds 9o *A! $hythm (for &atients with 3"= tracing : ta&e K second stri& below and analyCe' %his 3E= stri& visualiCes the &atients !5 of atrial fibrillation, and is slightly tachycardic (I think she had Gust gotten back from walking to the bathroom'. It is not a rhythmic. >rs. 2arding I need a little work on the vocab to be able to discuss this further. I know she has #)fib, which she is diagnosed with, its not a regular rhythm, and shes tachycardic from e4ertion. #lso I felt &ulses in her e4tremities, even with the a)fib.

"alf &ain bilaterally negative (ulses bilaterally eDual Irating scale; 7)absent, /)barely &al&able, +)weak, .)normal, 0)boundingJ #&ical &ulse; "arotid; Brachial; $adial; 6emoral; (o&liteal; !(; (%; 9o tem&oral or carotid bruits 3dema; Irating scale; 7)none, W/ (/)+mm', W+ (.)0mm', W. (?)Kmm', W0(F)<mm' J ocation of edema; 3 &itting non)&itting 34tremities warm with ca&illary refill less than . seconds

GI/GU: Bowel sounds active 4 0 DuadrantsH no bruits auscultated 9o organomegaly (ercussion dull over liver and s&leen and tym&anic over stomach and intestine #bdomen non)tender to &al&ation 8rine out&ut; "lear "loudy "olor; (revious +0 hour out&ut; m s 9-# 6oley "atheter 8rinal or Bed&an Bathroom (rivileges without assistance or with assistance "A# &unch without rebound tenderness ast B>; (date + - +7 - /0 ' 6ormed 1emi)formed 8nformed 1oft 2ard iDuid Batery "olor; ight brown >edium Brown !ark Brown Tellow =reen Bhite "offee =round >aroon Bright $ed
2emoccult &ositive - negative (leave blank if not done'

=enitalia; "lean, moist, without discharge, lesions or odor Other : !escribe;

9ot assessed, &atient alert, oriented, denies &roblems

M)$*)#!$4e#eta#: 6ull $O> intact in all e4tremities without cre&itus 1trength bilaterally eDual at QQQQ?QQQ $83 QQQQ?QQQ 83 QQQQ?QQQ $ 3

R QQQ?QQQQ in

Irating scale; 7)absent, /)trace, +)not against gravity, .)against gravity but not against resistance, 0)against some resistance, ?)against full resistanceJ Bas not able to assess fully as &atient was slee&ing))) I did assess while she walked and ate in the morning and she seemed to have full range of motion and strength in all e4tremities.

vertebral column without ky&hosis or scoliosis))) (atient is tallP 9eurovascular status intact; &eri&heral &ulses &al&able, no &ain, &allor, &aralysis or &arathesias

Ne)r!#!, *a#: (atient awake, alert, oriented to &erson, &lace, time, and date "onfusedH if confused attach mini mental e4am "9 +)/+ grossly intact (!id not assess s&ecifically, through observation only' 1ensation intact to touch, &ain, and vibration $ombergs 9egative (did not assess, but witnessed &atients ability to walk with no discernable difficulties or loss of balance.' 1tereognosis, gra&hesthesia, and &ro&rioce&tion intact (was not able to assess' =ait smooth, regular with symmetric length of the stride !%$; Irating scale; 7)absent, W/ sluggish-diminished, W+ active-e4&ected, W. slightly hy&eractive, W0 2y&eractive, with intermittent or transient clonusJ
%rice&s; Bice&s; (was not able to assess' Brachioradial; (atellar; #chilles; #nkle clonus; &ositive negative Babinski; &ositive negative

L1< PERTINENT LA2 VALUES AND DIAGNOSTIC TEST RESULTS (include &ertinent normals as well as abnormals, include rationale and analysis. ist dates with all labs and diagnostic tests'; (ertinent includes labs that are checked when on certain medications, monitored for the disease &rocess, need &rior to and after surgery, and &ertinent to hos&italiCation. !o not forget to include diagnostic tests, such as 8ltrasounds, 5)rays, "%, >$I, 2I!#, etc. If a lab or test is not in the chart (such as one that is done &reo&' then include why you e4&ect it to be done and what results you e4&ect to see. La( BB"; <.F B9 B89; S B9 "reatinine; 7.< B9 (otassium; 0.7 B9 1odium; /.? B9 2gb; /+./ B9 I9$; ..0 B9 B9(; ?07 2igh (latelet; +0S B9 =lucose; /?+ 2igh Osmolality;+F+ ow #lbumin; ../ ow 9O$># ; BB"; 0?77)/7777 B89; F)+7 "reatinine; 7.?)/.0 (otassium; ..?)? 1odium; /.?)/0? Date$ +-+7-/0 (atient has only had one lab drawn. I9$ levels are high because the &atient is &rescribed Barfarin but was not taking it at the hos&ital (I couldnt figure out why in her chart, but she wasnt'. Tre"1 1ince only one lab has been drawn, we cannot discuss the trends. Be would however like all of our normal values to stay B9 . =lucose values may re&resent a tem&orary s&ike after ingestion of a meal. ow osmolality and albumin levels are concerning, and we would want to correct that by increasing nutritional intake. 6rom the &anel, our real concern is the high levels of B9( which indicates heart failure. A"a#/$ $ 2igh BB"s, 9eutro&hils and >onocytes indicate the &resence of an infection or inflammation. %hese lab values are im&ortant to watch during a hos&ital stay as an infection contracted in the hos&ital can result in forfeiture of insurance com&ensation. (latelet levels are im&ortant to trend in someone with a history of %I#, high levels of &latelets could result in a future %I# or "A# due to an increased coagulability of blood. !ecreased levels of

2gb; /+.7)/? (female' I9$; 7.<)/.+ B9(; V/77 (latelet; /?7).77 =lucose; K7)//7 Osmolality; +F?)+S? #lbumin; ..+)?

hematocrit, hemoglobin and $B"s can be caused by blood-fluid loss. # high blood glucose in a &atient with no history of diabetes may be due to stress, this is an im&ortant value to monitor since the &atient is on a beta blocker which can mask sym&toms of hy&oglycemia, which can be life threatening. Osmolality and #lbumin levels must be monitored in &atient with "26 as they drive oncotic &ressure and decrease edema and fluid loss into tissue. >ost critically, B9( levels measure the e4acerbation of heart failure of the ventricles of the heart and are a means to measure &reload. # value greater than /77 indicates heart failure, any dro& below current levels would be an im&rovement.

K2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (!iet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. #lso &rovide rationale and freDuency if a&&licable.' (atient is scheduled for vitals and #ccuchecks 21#" and has been &rescribed a cardiac diet. (atient is allowed full bathroom and activity &rivileges. abs were drawn this morning but have not been returned from the lab. %he &atient will continue to be monitored for e4acerbations and ho&efully im&rovement of "26 sym&toms after her administration of IA asi4 by monitoring B9( levels and further "5$s to visualiCe removal of fluid from lungs.

A NURSING DIAGNOSES (actual and &otential ) listed in order of &riority'

/. !ecreased cardiac out&ut r-t im&aired cardiac function, increased &reload, decreased contractility, and increased afterload. +. $isk for im&aired gas e4change r-t e4cessive fluid in interstitial s&ace of lungs. .. $isk for 1hock (cardiogenic' r-t decreased contractility of heart and increased afterload. 0. 34cess fluid volume r-t im&aired e4cretion of sodium and water. ?. 6ear r-t threat to ones own well)being. K. "onsti&ation r-t activity intolerance. F. 6atigue r-t disease &rocess with decreased cardiac out&ut. <. (owerlessness r-t illness)related regimen. S. $eadiness for enhanced self)health management

L 1& CARE PLAN N)r$ ", D a,"!$ $: !ecreased cardiac out&ut r-t im&aired cardiac function, increased &reload, decreased contractility, and increased afterload. #3B; !ecreased B(, decreased &eri&heral &ulses, &allor, O" changes, decreased O+ saturation, decreased ca&illary refill, decreased &ulse rate and dys&nea. Pat e"t G!a#$/O)t*!'e$ N)r$ ", I"ter6e"t !"$ t! A*0 e6e Rat !"a#e 3!r I"ter6e"t !"$ E6a#)at !" !3 G!a# !" Da/ *are $ G!a# Pr!6 1e Re3ere"*e$ Pr!6 1e1 S0!rt Ter': "lient will #dminister O+ &er >! orders 1u&&lemental O+ increases O+ Tes, &atient demonstrated adeDuate demonstrate adeDuate cardiac availability to the myocardium. cardiac out&ut. out&ut #3B blood &ressure, &ulse rate and rhythm within normal >onitor orthostatic B( 21#" and %hese interventions assess for fluid (atient received education on &arameters for clientH strong daily weights. volume status. im&ortance of consistently taking &eri&heral &ulsesH maintained level cardiovascular medications, and of mentation, lack of chest >onitor (assess D+h' and re&ort %hese are signs and sym&toms their actions, and which side effects discomfort or dys&nea, and &resence and degree of sym&toms consistent with heart failure and to re&ort. adeDuate urinary out&utH an ability including dys&nea at rest or with decreased cardiac out&ut. to tolerate activity without reduced e4ercise ca&acity, sym&toms of dys&nea, synco&e or ortho&nea, &aro4ysmal nocturnal chest &ain. L!", Ter': $emain dys&nea, nocturnal cough, free of side effects from the distended abdomen, fatigue, or medications used to achieve weakness. >onitor and re&ort signs adeDuate cardiac out&ut. including Gugular vein distension, 1. gallo&, rales, &ositive he&ato) Gugular refle4, ascites, laterally dis&laced or &ronounced (>I, heart murmurs, narrow &ulse &ressure, cool e4tremities, tachycardia with &ulsus alternans, and irregular heartbeat. %itrate inotro&ic and vasoactive medications within defined &arameters to maintain contractility, &reload, and afterload &er &hysicians orders. "linical &ractice guidelines recommend that intravenous inotro&ic drugs might be reasonable for 26 clients &resenting with low B( and low cardiac out&ut to maintain systemic

&erfusion and &reserve end)organ &erformance. By following &arameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, while maintaining adeDuate &erfusion of the body. %each the client im&ortance of consistently taking cardiovascular medications, and include actions, side effects to re&ort. # scientific statement cited that adherence to medications ranges from ?O)S7O. In one study <<O adherence was reDuired in heart failure clients to achieve event)free survival. %he study cited as reasons for non)adherence, de&ression, cost, attitudes about taking medication, worrying about or feeling side effects including those on se4ual functioning, recei&t of conflicting information about medications from different &rescribers, and lack of understanding about discharge instructions. 3vidence)based guidelines state that taking medication as directed can hel& &revent 26 decom&ensation, and rehos&italiCation, and decrease morbidity. (ost discharge su&&ort can significantly reduce hos&ital readmissions and im&rove healthcare outcomes, Duality of life, and costs.

Instruct client and family on the im&ortance of regular follow u& care with &roviders.

L2 DISCHARGE PLANNING: (&ut a X in front of any &t education in above care &lan that you would include for discharge teaching'
C!"$ 1er t0e 3!##!9 ", "ee1$: Y11 "onsult X!ietary "onsult Y(%- O% Y(astoral "are Y!urable >edical 9eeds X6-8 a&&ts X>ed Instruction-(rescri&tion X are any of the &atients medications available at a discount &harmacy@ XTes Y 9o Y$ehab- 22 Y(alliative "are

L 1& CARE PLAN N)r$ ", D a,"!$ $: $isk for im&aired gas e4change r-t e4cessive fluid in interstitial s&ace of lungs. #3B; !ecreased &ulse o4imetry, inability to move secretions, decreased ca&illary refill, &ulmonary effusion secondary to "26. Pat e"t G!a#$/O)t*!'e$ N)r$ ", I"ter6e"t !"$ t! A*0 e6e Rat !"a#e 3!r I"ter6e"t !"$ E6a#)at !" !3 I"ter6e"t !"$ !" G!a# Pr!6 1e Re3ere"*e$ Da/ *are $ Pr!6 1e1 S0!rt Ter': !emonstrate >onitor res&iratory rate, de&th, and 9ormal res&iratory rate is /7 to +7 (atient demonstrated im&roved im&roved ventilation and adeDuate ease of res&iration (D+h'. Batch for breaths-min in the adult. # study ventilation and adeDuate o4ygenation as evidenced by &ulse use of accessory muscles and nasal demonstrated that when the o4ygenation #3B &ulse o4imetry o4imetry within normal &arameters flaring. res&iratory rate e4ceeds .7 within normal limits (<<O)S+O'. (<<O)S+O.' L!", Ter': breaths-min, along with other (atient did not receive education on AerbaliCe understanding of O+ &hysiological measures, a O+ su&&lementation and other su&&lementation and other significant cardiovascular or thera&eutic interventions, and was thera&eutic interventions. res&iratory alteration e4ists. not able to verbaliCe their im&ortance. %his education will be #uscultate breath sounds every /)+ %he &resence of wheeCes may alert rescheduled to occur before hours. isten for diminished the nurse to airway obstruction, discharge. breath sounds, crackles, and which may lead to or e4acerbate wheeCes. e4isting hy&o4ia. In severe e4acerbations of "O(!, lung sounds may be diminished or distant with air tra&&ing. >onitor the clients behavior and mental status D+h for the onset of restlessness, agitation, confusion, and (in the late stages' e4treme lethargy. If the client is acutely dys&enic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. "hanges in behavior and mental status can be early signs of im&aired gas e4change. In the late stages the client becomes lethargic and somnolent. eaning forward can hel& decrease dys&nea, &ossibly because gastric &ressure allows better contraction of the dia&hragm. %his is called the tri&od &osition and is used during times of distress, including when walking, leaning forward on the walker.

#dminister humidified O+ through an a&&ro&riate device (e.g. nasal cannula or venture mask &er the &hysicians-&rovider order'H aim for an O+ saturation level of S7O O+ saturation or above. Batch for onset of hy&oventilation as evidenced by increased somnolence. %each the client how to &erform &ursed)li& breathing and ins&iratory muscle training, and how to use the tri&od &osition. 2ave the client watch the &ulse O+ to note the im&rovement in O+ with these breathing techniDues. %each the client energy conservation techniDues and the im&ortance of alternating rest &eriods with activity. Instruct the family regarding home O+ thera&y if ordered (e.g., delivery system, liter flow, safety &recautions, number of tanks needed'.

1u&&lemental O+ should be titrated to im&rove the clients hy&o4emia with a target of <<O)S+O O+ saturation in order to avoid e4cessive O+ thera&y which may lead to "O+ narcosis.

1tudies have demonstrated that &ursed)li& breathing was effective in decreasing breathlessness and im&roving res&iratory function. # systematic review found that ins&iratory muscle training was effective in increasing endurance of the client and decreasing dys&nea.

ong)term O+ thera&y can im&rove survival, e4ercise ability, slee& and ability to think in hy&o4emic clients. "lient education im&roves com&liance with &rescribed use of O+.

L DISCHARGE PLANNING: (&ut a X in front of any &t education in above care &lan that you would include for discharge teaching' C!"$ 1er t0e 3!##!9 ", "ee1$: Y11 "onsult X!ietary "onsult Y(%- O% Y(astoral "are X!urable >edical 9eeds X6-8 a&&ts X>ed Instruction-(rescri&tion X are any of the &atients medications available at a discount &harmacy@ XTes Y 9o Y$ehab- 22 Y(alliative "are

L 1& CARE PLAN Pat e"t G!a#$/O)t*!'e$ N)r$ ", D a,"!$ $: N)r$ ", I"ter6e"t !"$ t! A*0 e6e Rat !"a#e 3!r I"ter6e"t !"$ G!a# Pr!6 1e Re3ere"*e$ E6a#)at !" !3 I"ter6e"t !"$ !" Da/ *are $ Pr!6 1e1

L DISCHARGE PLANNING: (&ut a X in front of any &t education in above care &lan that you would include for discharge teaching' C!"$ 1er t0e 3!##!9 ", "ee1$: Y11 "onsult Y!ietary "onsult Y(%- O% Y(astoral "are Y!urable >edical 9eeds Y6-8 a&&ts Y>ed Instruction-(rescri&tion Y are any of the &atients medications available at a discount &harmacy@ YTes Y 9o Y$ehab- 22 Y(alliative "are

L 1& CARE PLAN Pat e"t G!a#$/O)t*!'e$ N)r$ ", D a,"!$ $: N)r$ ", I"ter6e"t !"$ t! A*0 e6e Rat !"a#e 3!r I"ter6e"t !"$ G!a# Pr!6 1e Re3ere"*e$ E6a#)at !" !3 I"ter6e"t !"$ !" Da/ *are $ Pr!6 1e1

L DISCHARGE PLANNING: (&ut a X in front of any &t education in above care &lan that you would include for discharge teaching' C!"$ 1er t0e 3!##!9 ", "ee1$: Y11 "onsult Y!ietary "onsult Y(%- O% Y(astoral "are Y!urable >edical 9eeds Y6-8 a&&ts Y>ed Instruction-(rescri&tion Y are any of the &atients medications available at a discount &harmacy@ YTes Y 9o Y$ehab- 22 Y(alliative "are

Borks "ited 3riksonLs 1tages of (sychosocial !evelo&ment. (+7/.'. $etrieved from; htt&;--&sychology.about.com-library-blQ&sychosocialQsummary.htm 2eart 6ailure. (+7/0'. $etrieved from; htt&;--en.wiki&edia.org-wiki-2eartQfailureZ(atho&hysiology 2obbs, $obert and Boyle, #ndrew. 2eart 6ailure. (+7/0'. $etrieved from; htt&;--www.clevelandclinicmeded.com-medical&ubs-diseasemanagement-cardiology-heart)failure-Z&atho&hysiology