UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Eduardo Alegria

PATIENT ASSESSMENT TOOL Assignment Date: 06/10/16

LONG FORM FUNDAMENTALS
Agency: Tampa General Hospital
Patient Initials: G.S.

Age: 76

Admission Date: 05/27/16

Gender:

Marital Status: Married

Occupation: Retired

Female

Primary Language: English

Level of Education: Teacher

Number/ages children/siblings: 2 sons (ages 58, 46) and 1

daughter (age 56)

Primary Medical Dx: Mitral valve regurgitation, AKI (Acute

Kidney Injury), chest pain-atypical, Elevated natriuretic
peptide (BNP) level.
Advanced Directive: Yes, Living Will

Living Arrangements: one story house in St. Petersburg;

(no stairs). Patient lives with her daughter to facilitate
care and transportation to medical appointments.
Immunizations: Childhood see below.

Code Status: Not on file.

Culture/ Ethnicity /Nationality: African-American

Surgery Date: N/A (Patient is non-operable) Procedure: N/A

Religion: Christian non-denominational

Type of Insurance: Medicare

2
CC: Shortness of breath. Patient states: started last night before I went to sleep; it continued this morning. I was
thankful that I had an appointment with my primary physician today. Patient is being seen for a leaky aorta
and hx of Congestive Heart Failure (CHF).
+3 HPI: OLD CART
On the night of 05/26/16, the patient was in her bed ready to go to sleep and started to feel shortness of breath. Patient
states that she couldnt sleep well but knew she had an appointment the next day with her primary care physician. Pt.
attended the appointment where she felt that the shortness of breath was getting worse during the consult. Pts Dr. called
911 and directed the paramedics to take her to TGH for further evaluation. At TGHs ED, Pt. was seen and dx with Mitral
valve regurgitation, Acute Kidney Injury, (AKI), chest pain-atypical, Elevated natriuretic peptide (BNP) level. Pt was d/c
from the ED and admitted on 5A2. The patient reports occasional, sharp pain in her chest (8 out of 10) and shortness of
breath, at times. She reports that the pain, as well as the shortness of breath, comes and goes. She was prescribed medicine
PRN, which reportedly makes the pain better, and tx with a nebulizer. Pt. is currently under 2L of O2 through nasal
cannula. This patient was also waiting for her medical team to meet with her to explain medication and tx options.

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 2 PMH/PSH Hospitalizations for any medical illness or operation

Father

72

Heart Attack

Mother

67

UNK

Brothers

UNK Heart problems

Sisters

UNK Heart problems

relationship
relationship
relationship

Comments: Pt. has a PFH of heart problems, as well as HTN. Pt. is the last of 11 siblings alive.

1 IMMUNIZATION HISTORY
YES

NO

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Overdue 09/13/1958)
Adult Tetanus (Overdue 09/13/1958)
Influenza (flu) (09/01/2016)
Pneumococcal (pneumonia) (Overdue 09/13/2004)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
**Health Maintenance Modifiers: Pt. is high risk for influenza complications and pneumococcal disease. Pt. should
be assessed annually. Pt. was educated (by myself) on the possible co-morbidities with these overdue vaccinations.

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Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Management/Treatment
Cardiac Surgery
Cardiac Catheterization, Cardiac Angioplasty
nebulizer tx, 2L O2 through nasal cannula.
nitroglycerin (0.4 mg SL Tab), ranolazine (500mg
x1 24hr).
aspirin (x1 81mg chewable), 2L O2 through
cannula, CXR, diltiazem (x1inj. 10 mg)
UNK
UNK
nebulizer tx, 2L O2 through cannula. CXR

Bleeds Easily

Cause
of
Death
(if applicable)

Asthma

Hyperlipidemia
Chronic Kidney Disease
Shortness of Breath

Arthritis

UNK
UNK
05/27/16

Anemia

Hypertension

Environmental
Allergies

08/02/12-08/03/12

Alcoholism

CAD
CHF
Shortness of Breath
Arrhythmia

2 FMH

Operation or Illness

Age (in years)

Date
08/02/12
08/03/12
08/02/12-08/03/12
08/03/12

 1 Allergies or
Adverse Reactions

Medications

NAME of
Causative Agent
diphenhydramine
Benadryl
amiodarone analogue
codeine
Coumadin
Iodine, Iodine cont.
Multivitamins
No

Type of Reaction (describe explicitly)

Nausea and vomiting
Nausea and vomiting, restless/agitated legs
Difficulty breathing
Nausea and vomiting
Cough
Itching and swelling of hands

Other (food, tape,

dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis,
prognosis or treatment)
MoD: During ventricular systole, this condition causes a backflow of blood from the left ventricle to the left atrium,
producing a murmur. The left ventricle dilates and hypertrophies in order to maintain normal cardiac functions. As the
backflow of blood increases, atrial fibrillation occurs. The valve structures enlarge, giving way to further blood backflow,
eventually resulting in left ventricular failure, pulmonary hypertension, and right ventricular failure (Huether, S.,
McCance, K., 2013).
R/F: Mitral regurgitation is often associated with childhood rheumatic heart disease, mitral valve prolapse, dilated
cardiomyopathy, and infectious endocarditis (Huether, S., McCance, K., 2013).
How to Diagnose: Clinical assessments typically start with ECG/EKG, but CT scans and MRI are not foreign to this
practice.
S/S: Atrial fibrillation, angina, shortness of breath, fatigue, and/or light-headedness (Huether, S., McCance, K., 2013).
How to Treat: Supportive care, inclusive of monitoring for changes or improvement, valve replacement surgery, lowsodium diet, lowering risk of stroke with use of anticoagulant medications (Huether, S., McCance, K., 2013)

5 MEDICATIONS: (Include both prescription and OTC)

Name: apixaban (Eliquis)

Concentration: 5 mg

Route: PO

Dosage Amount: 5 mg tablet

Frequency: BDS

Pharmaceutical class: Anticoagulant Medication

Home:

Hospital:

or

Both: X

Indication: apixaban is used on patients with atrial fibrillation; prevents the risk of strokes by keeping the platelets form coagulating inside the veins.
Adverse effects: Blood and lymphatic system disorders, G.I. hemorrhage, ecchymosis
Side effects: Increased risk of thrombotic events after premature discontinuation, bleeding
Nursing considerations/ Patient Teaching: Increased risk of bleeding while taking them with other anticoagulants/Instruct patient to take apixaban as directed, inform
patient that she might bruise and bleed more easily. Notify the physician if signs of bleeding occur or if any injury occurs, especially head injury.
Name: aspirin

Concentration: 81 mg

Route: PO

Dosage Amount: x1 81 mg tablet

Frequency: daily

Pharmaceutical class: Anticoagulant Medication

Home:

Hospital: or

Both: X

Indication: Decreases platelets, aggregation is also used for its analgesic effects and to reduce inflammation and fever by inhibiting the production of prostaglandins

University of South Florida College of Nursing Revision May 2012

Adverse effects: GI bleeding, anaphylaxis, laryngeal edema

Side effects: dyspepsia, nausea, abdominal pain, vomiting, rash, Urticaria
Nursing considerations/ Patient Teaching: Monitor for the onset of tinnitus, hyperventilation, agitation, mental confusion/Instruct patient to avoid use of alcohol to
minimize gastric irritation, avoid taking it with acetaminophen or NSAIDs to prevent analgesic nephropathy. Monitor platelets
Name: calcitriol (Rocaltrol)

Concentration: 0.5 mcg

Route: PO

Dosage Amount: 0.5 mcg capsule

Frequency: daily

Pharmaceutical class: Vitamin D analogue

Home:

Hospital:

or

Both: X

Indication: Management of hypocalcemia in chronic renal patients

Side effects: loss of appetite, constipation, dry mouth, headache, vomiting
Adverse Effects: Dermatitis, Acute blistering, Poisoning by vitamin D, Hypercalcemia syndrome
Nursing considerations: Monitor vitamin D levels in patients as well as electrolyte imbalance
Name: nitroglycerin (Nitrostat)

Concentration: 0.4 mg

Route: PO

Dosage Amount: 0.4 mg SL Tablet

Frequency: PRN for acute anginal pain

Pharmaceutical class: Nitrates

Home

Hospital

or

Both: X

Indication: Angina pectoris, CHF, Hypertension,

Side effects: Hypotension, flushing, dizziness, headache, lightheadedness
Adverse Effects: Anaphylactoid reaction, methemoglobinemia, increase ICP.
Nursing considerations: Monitor orthostatic pressure, counsel pt. to raise slowly from bed, advise pt. to report s/s of unstable angina
Name: ranolazine (Ranexa)

Concentration: 500 mg

Route: PO

Dosage Amount: 500 mg 12hr Tablet

Frequency: daily

Pharmaceutical class: Anti-anginals

Home:

Hospital:

or

Both: X

Indication:
Side effects: Dizziness, headache, constipation, nausea
Adverse Effects: Prolonged QT interval, vasovagal syncope.
Nursing considerations: Monitor pt. for constipation as well as pts heart monitor. Teach pt. to swallow the pill whole and that this medication is not indicated for acute
angina
Name: Valsartan (Diovan)

Concentration: 40 mg

Route: PO

Dosage Amount: 40 mg
Frequency: BID

Pharmaceutical class: Angiotensin II Receptor Antagonists

Home

Hospital

or

Both X

Indication: Treats hypertension by blocking the vasoconstrictor and aldosterone-secreting effects of angiotensin II at various receptor sites.
Side effects: dizziness, fatigue, headache, insomnia, weakness, chest pain, edema, nasal congestion, back pain, and hyperkalemia.
Adverse Effects: Angioedema, Acute renal failure
Nursing considerations: Monitor pts blood pressure before this medication is given, Teach pt. to avoid potassium supplements and salt substitutes due to being high in
potassium

4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Cardiac
Analysis of home diet (Compare to food pyramid and
Consider co-morbidities and cultural considerations):

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Diet pt follows at home? Low-Sodium, Healthy heart diet

Breakfast: scrambled eggs, slices of wheat bread (x2

toasted), and carrot juice (1 glass)

As the graph shows, the patient is eating the correct amount

of vegetables, whole grains, and proteins. She is lacking in
eating any fruits. Since the pt. is taking calcitriol, she is
doing a good job not taking more calcium in her diet. The
patient watches her sodium intake due to her history of
vascular problems; it is currently 1841mg, while her daily
limit is 2300 mg. The patient is way under her allotted
sugars and carbohydrates intake, as well as fiber. The total
amount of calories eaten using this example comes to 921,
which is below the recommended daily intake of 1600;
however, this pt. does not and cannot achieve the
recommended physical activity for her age due to her
illnesses and medical conditions. My recommendation
would be to encourage her to increase her fiber intake
through fruits, such as apples, strawberries, and raspberries
(with the highest amount of fiber - 8 grams per cup).

Lunch: turkey sandwich

Dinner: 2 cups garden salad (lettuce, tomato, carrots),
chicken skinless breast
Snacks: multigrain chips, oat and honey granola bars

2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My daughter and son-in-law (she moved to their house upon the daughters request)
How do you generally cope with stress? or What do you do when you are upset?
I used to go out and window-shop at the mall.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
The patient feels depressed that she is not able to do what she used to. Cooking for her kids and grandkids used to be
something that she enjoyed. She does not like to experience shortness of breath and have to ask her children for help.
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are

University of South Florida College of Nursing Revision May 2012

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.

5 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

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

Give the textbook definition of both parts of Ericksons developmental stage for your patients age group:

Since this pt. is 76 years of age, she is in Ericksons developmental stage of Ego Integrity vs. Despair. Ego integrity means
that a person at this age (65+ yrs) starts to see life as a retiree, feels happy with their accomplishments, and lives a life of
integrity due to their successful life. Despair means that in this stage, the person could take another turn and feel
unaccomplished. If these feelings occur, the person may feel a terrible guilt for the life that they have lived (McLeod,
2013).

Describe the characteristics that the patient exhibits that led you to your determination:

This pt shows signs of Ego Integrity because she was able to look back on her life with happiness, she was friendly, she
did not talk about life regrets, and she was so proud of her children and grandchildren. The patient stated I am still young
at heart.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patient has CHF, CAD, shortness of breath, HTN, kidney problems, mitral valve regurgitation so this has taken a toll
on her happiness. At times she feels depressed because she doesnt want to be a burden for her children and not be there
for her grandchildren.

+3Cultural Assessment:
What do you think is the cause of your illness?
The patient believes that the cause of her illness is past family medical history related and rheumatic fever when she was a
child.
What does your illness mean to you?
To this patient, her illness gets in the way of doing things that she was used to and occasionally makes her feel depressed
that she has to ask her children for help.

+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 May 2012

Do you prefer women, men or both genders? __________Male______________________________________________

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? ______No________________________________
Are you currently sexually active? _____No______ When sexually active, what measures do you take to prevent
acquiring a sexually transmitted disease or an unintended pregnancy? _____No__________________________
How long have you been with your current partner? 59 years._______________
Have any medical or surgical conditions changed your ability to have sexual activity? ______No_________________
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 May 2012

+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?

Yes
No X
For how many years?
(age

thru

If applicable, when did the

patient quit?
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?

Yes

No X
For how many years? N/A
(age

thru

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No X
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No X

thru

If not, when did he/she quit?

N/A

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

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REVIEW OF SYSTEMS (TO BE USED FOR DATA COLLECTION ONLY)

General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Daily
Other:

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
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: AOther:

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

5 x/day

Hematologic/Oncologic

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

2x/day
2x/year

Pulmonary
Difficulty Breathing
Cough - X dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 05/27/2016
Other: SOB r/t pulm. Edema

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever as a child
Myocarditis
Arrhythmias - A fib
Last EKG screening, when? 05/27/16
Pt is on the monitor

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self-breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 10 years ago
menstrual cycle
regular
irregular
menarche
age? 13
menopause
age? 47
Date of last Mammogram &Result: 2014
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
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
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other: Rheumatic fever

University of South Florida College of Nursing Revision May 2012

+10 REVIEW OF SYSTEMS: (Include health promotion/maintenance activities)

General Overall Health Status:
The patient is an overweight, elderly African-American woman. She is dressed appropriately for the season and appears to
be well-nourished. The patient is currently sitting on her bed. The patient has trouble ambulating, gets easily tired and
requires a person to help her get to the bathroom to use the toilet and brush her teeth.

Integumentary:
The patient has some ecchymosis and liver spots on her face, arms, and legs due to her age. The patient denies
problems with nails, dandruff, psoriasis, hives, and rashes. The patient uses lotion and showers daily.
HEENT:
The patient has lost some vision and requires glasses to see. The patient denies a history of cataracts, glaucoma, difficulty
hearing, ear infections, nosebleeds, post-nasal drip, oral infection, and/or dental problems. The patient does not have
dentures or implants.
Pulmonary:
The patient has dry cough at times, possibly for poor O2 exchange at the alveoli level, but denies asthma, bronchitis,
emphysema, pneumonia, and tuberculosis.
Cardiovascular:
The patient has shortness of breath, has a history of chest pains, and is currently taking medication for hypertension, acute
angina and non-anginals pains. Patient has history of CHF, CAD, Rheumatic fever as a child associated with Rheumatic
pancarditis.

10 REVIEW OF SYSTEMS: (continued)

GI:
The patient denies a history of nausea, vomiting, diarrhea, irritable bowel syndrome, and other gastrointestinal problems.
GU:
The patient denies any GU problems.
Musculoskeletal:
The patient denies history of Arthritis or any musculoskeletal pain.
Neurological:
The patient denies any history of anxiety.
Endocrine:
The patient has no history of diabetes, severe headaches, ticks, tremors, and seizures.

Hematologic:

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The patient denies bleeding and bruising easily, cancer, and having blood transfusions. Her blood type is O+.

PHYSICAL EXAMINATION(TO BE USED FOR DATA COLLECTION ONLY)

Orientation and level of Consciousness: A&Ox4
General Survey: The patient is Height: 51
Weight: 157 BMI: 28.3
Pain: 0
overweight, older, well kept, Pulse: 122
Blood Pressure:
not in distress, AfricanUpper right arm, 133/72
American woman.
Temperature: (route taken?)
Respirations: 18
Oral 97.9
SpO2 100%
Is the patient on Room Air or O2: O2 via nasal cannula
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
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
apathetic
bizarre
agitated
anxious
tearful
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

Peripheral IV site Type: IV lock

no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge

talkative
withdrawn

Location: Right hand

Location:

quiet
boisterous
aggressive
hostile

Date inserted: 06/03/16

Date inserted:

University of South Florida College of Nursing Revision May 2012

flat
loud

Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

Location:

Date inserted:

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
left eye - 20/20
with corrective lenses
Functional vision: right eye left eye without corrective lenses right eye - 20/20
Functional vision both eyes together:
with corrective lenses or
NA
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- 12 inches & left ear- 12
inches
Weber test, heard equally both ears
Rinne test, air
time(s) longer than bone
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: White teeth and intact
Comments:
Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear X
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Tactile fremitus bilaterally equal without overt vibration
CR - Crackles
Sputum production: thick thin
Amount: scant small moderate large
RH Rhonchi
Color: white pale yellow yellow dark yellow green gray light tan brown red
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercoastal space midclavicular line
Heart sounds: S1 S2 Regular
Irregular X
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze) Patient on telle-monitor due to A-fib

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid:2+ Brachial: 2+ Radial: 2+ Femoral: 2+
Popliteal:2+
DP:1+
PT: 1+
No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

University of South Florida College of Nursing Revision May 2012

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Liver span
8 cm
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
light yellow
Previous 24 hour output:
mLs N/A X
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance X
CVA punch without rebound tenderness
Last BM: (date 06 / 01 / 16 )
Formed X Semi-formed
Unformed
Soft X Hard
Liquid
Watery
Color: Light brown
Medium Brown X Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: o Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __5_____ in UE & ___5____ in LE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
The patients left leg has limited ROM due to the recent hip surgery.
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
X Babinski: positive negative

Brachioradial: +2

Patellar: +2

Achilles:

+2

Ankle clonus: positive negative

Patient demonstrates good balance, no shuffling gait, but walks with assistance due to extreme fatigue

+10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS: (include rationale and analysis)
WBC: between 5.33 - 7.90 - WDL of 3.5-10.5 billion cells/L.
RBC:
3.93 - 4.35 trillion cells/mcL should be 3.90-5.03.
HGB:
11.8 12.5 WDL of 12-15.5 grams/dL.
K+:
4.1 4.5 WDL of 3.5 5.0 mEq/L
BUN:
50-58 WDL of 7 20 mg/dL
CREA:
2.1 2.3 WDL of 0.6 1.1 mg/dL
TROP:
0.039 0.043 WDL of <0.01 - >0.01 ng/mL.
BNP:
2892
WDL 100 300 pg/mL
These values were obtained from 05/27/16 to 06/03/16.
The patients normal white blood cell count (WBC) is WDL indicating the patient is not currently fighting off
an infection. The patients red blood cell count is WDL, indicating she is not currently anemic. A borderline low
normal mean corpuscular hemoglobin value indicates her red blood cells are carrying less than the average
amount of hemoglobin per red blood cell. The patients potassium count is WDL, indicating that her current
medications are helping with her arrhythmias. Her elevated BUN is consistent with a dx of acute kidney injury,
University of South Florida College of Nursing Revision May 2012

as well as heart failure. The patients elevated creatinine indicates that her kidneys are not fully functional. The
elevated troponin is also associated with heart damage. The patients elevated BNP levels indicate severe heart
failure.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

The patient was waiting for her medical teams evaluation results and recommendations regarding treatment
options and procedures.

2 Medical Diagnoses
(as listed on the chart)

8 Nursing Diagnoses
(actual and potential - listed in order of priority)

1. Mitral valve regurgitation

1. Activity intolerance r/t imbalance between oxygen

supply and demand (Ackley & Ladwig, 2011).

2. Acute Kidney Injury

2. Decreased cardiac output r/t incompetent heart valves,

abnormal forward or backward blood flow, flow into a
dilated chamber, flow through an abnormal passage
between chambers (Ackley & Ladwig, 2011).

3. Chest pain, atypical, elevated brain natriuretic peptide

3. Risk for impaired tissue integrity r/t the usage of nasal

cannula (Ackley & Ladwig, 2011).

University of South Florida College of Nursing Revision May 2012

4.

4. Risk for falls r/t impaired physical mobility (Ackley &

Ladwig, 2011).

5.

5.

University of South Florida College of Nursing Revision May 2012

 15 for Care Plan

Nursing Diagnosis: Activity intolerance r/t imbalance between oxygen supply and demand (Ackley & Ladwig, 2011)
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions Evaluation of Interventions
Achieve Goal
Provide References
on Day care is Provided
Patient will increase muscle
strengthening activities that
involves the lower extremities
during hospital stay (Ackley &
Ladwig, 2011).

* Screen for mobility skills in the

following order: bed mobility,
supported and unsupported sitting,
transition movements, and
standing and walking activities.

* The abilities of the patient should

be assessed to determine the best
facilitated movement (Ackley &

* The clients abilities were

assessed and discussed before the
physical activity.

Ladwig, 2011).

(Ackley & Ladwig, 2011).

Patient will demonstrate use of

adaptive equipment to increase
mobility during hospital stay
(Ackley & Ladwig, 2011).

Allow for periods of rest before

* Provide information about
* The patient did receive
and planned exertion periods such advocacy, accessibility, assistive
information about the Americans
as meals, baths, treatments, and
technology, and issues under the
with Disabilities Act (Ackley &
physical activity (Ackley & Ladwig,
Americans with Disabilities Act
Ladwig, 2011).
2011).
(Ackley & Ladwig, 2011).
Patient will increase muscle
Refer the patient to physical
Six months of resistance exercise
The patient is working with
strengthening activities that
therapy for resistance exercise
for the elderly greatly increased
physical therapist team, she is
involves the lower extremities
training, including leg extension,
their aerobic capacity, possibly
exercising twice a day.
during hospital stay (Ackley &
leg curl, and calf press (Ackley &
from increased skeletal muscle
Ladwig, 2011).
Ladwig, 2011).
strength (Ackley & Ladwig, 2011).
Perform passive ROM exercises as
least twice a day unless
Inactivity rapidly contributes to
The patient is complying with a
contraindicated; repeat each
muscle shortening and changes in
passive ROM doing these
maneuver three times (Ackley &
periarticular and cartilaginous joint exercises every 2 hours.
Ladwig, 2011).
structure (Ackley & Ladwig, 2011).
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
X PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH
University of South Florida College of Nursing Updated April 2012

Palliative Care

Nursing Diagnosis: Risk for falls r/t impaired physical mobility (Ackley & Ladwig, 2011
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Achieve Goal
Provide References

Evaluation of Interventions
on Day care is Provided

Patient will remain free of falls

during hospital stay (Ackley &
Ladwig, 2011).
Patient will understand methods
to prevent injury at the hospital
and at home (Ackley & Ladwig, 2011).

A thorough fall-risk assessment

was performed; results placed pt.
at high risk for falls.
The patient consistently used the
call light to request assistance
getting to the toilet.

Complete a fall-risk assessment

for older adults using a valid and
reliable tool (Ackley & Ladwig, 2011).
Place call light within reach and
show how to call for assistance
(Ackley & Ladwig, 2011).

Upon discharge, the patient will be * Assess home environment for

educated as to how to change her
threats to safety, including clutter
home environment to minimize the and rugs (Ackley & Ladwig, 2011).
incidence of falls (Ackley & Ladwig,
2011).

The tool screens for primary

prevention of falls (Ackley &
Ladwig, 2011).
Placing the call light near the
patient will encourage her to seek
assistance when needing to use the
toilet (Ackley & Ladwig, 2011).
* Clients suffering from impaired
mobility are at risk for injury from
common hazards.

Although the Pts house has not

been assessed for safety, the
student nurse taught the house
owner (daughter) about safety and
threats that could potentially harm
the patient.
Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching) Patient was
educated on potential risks related to her illness and medical condition on 06/10/16 as per care-plan above. She was also educated on the following: fall risks
and techniques to mitigate injury, keeping a log diet, consuming a low carb/high fiber diet, skin maintenance, potential signs of illnesses, and exercise benefits.
Patient is not diagnosed with diabetes yet; therefore, she is not taking any medicine for this disease. Patient was instructed on what medications she is taking
during her hospitalization and verbalized good understanding, as evidenced by correctly answering the student nurses questions about such medications.

Consider the following needs:

SS Consult
X Dietary Consult
X PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? X Yes No
X Rehab/ HH
Palliative Care

University of South Florida College of Nursing Updated April 2012

University of South Florida College of Nursing Updated April 2012

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, Mo.: Elsevier.
Choose My Plate. (n.d.). Available at: http://www.choosemyplate.gov/
Clinical Pharmacology [database online]. Retrieved from http://www.clinicalpharmacologyip.com.ezproxy.hsc.usf.edu/default.aspx.
Huether, S., McCance, K. (2012) Alterations of Musculoskeletal Functions. Understanding
Pathophysiology. St. Louis, MO: Elsevier Mosby
McLeod, S. (2013). Erik Erikson. Psychosocial Stages. Simply Psychology. Retrieved from
http://www.simmplypsychology.org/Erik-Erikcon.htm

University of South Florida College of Nursing Updated April 2012