UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Jamie Steele

Assignment Date: 10/27/2015
PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: SMH
Patient Initials: CV Age: 58 Admission Date: 10/26/2015
Gender: Female Marital Status: Married Primary Medical Diagnosis with ICD-10 code:
Primary Language: English 786.5 Chest pain.
Level of Education: 1 year community college Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Progressive Management
Number/ages children/siblings: 6 siblings 59 is oldest and 51 is
Youngest, children 6- 38, 36, 35, 34, 32, 32.
Served/Veteran: No Code Status: Full
Living Arrangements: House Advanced Directives:
If no, do they want to fill them out?
Surgery Date: 10/29/2015 Procedure: CABG
Culture/ Ethnicity /Nationality: White
Religion: Roman Catholic Type of Insurance: Self Pay

1 CHIEF COMPLAINT: Chest Pain

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Experienced some chest pain, sharp radiating to Left shoulder and down left arm. EMS gave her Aspirin and
Nitroglycerin, which helped to relieve some of her pain. She had elevated D-dimer in the emergency department.
At first her troponins were negative but the next two troponins drawn were positive at 5.58 and 8.04.
O- 10/25/2015
L- Chest, Radiating to Left arm.
D- 7:30-8:30pm (until she arrived to ED)
C-sharp
A- nothing
R- Nothing
T- Nitroglycerin, Aspirin
S- Unknown

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date Operation or Illness
1985 Ankle surgery, removal of glass

Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

of Asthma

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Prostate
cancer,
Father 79
died on
OR table
Cancer,
Mother 75
Lung
Brother 59
Sister
relationship

relationship

relationship

Comments: Include date of onset

Brother had stents put in. Mother died 4 years ago, and also had COPD. Father died last December, and also had Kidney failure.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) 6 years ago
Adult Tetanus (Date) 6 years ago
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
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 Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
NKA

Medications

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
According to pages 597-600 of Huether and McCance, Coronary artery disease is typically caused by atherosclerosis, this
can lead down a path of myocardial ischemia and myocardial infarction. Both of these this patient has experienced. When
the vessels restrict blood supply often enough it can complete an occlusion causing an infarction.
Things that may cause CAD are women after menopause, advanced age, dyslipidemia, hypertension, smoking, obesity,
diabetes. This patient exhibits many of these risk factors for CAD.
Tests that may lead toward a diagnoses are elevated CRP, cholesterol levels low HDL and high LDL.
Treatment are prevention measures such as quitting smoking altering diet, weight loss, to lower risk of progression as this
patient already has exhibited CAD.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name Aspirin Concentration (mg/ml) Dosage Amount (mg) 162mg
Route PO Frequency Daily
Pharmaceutical class: salicylates Home Hospital or Both
Indication: mild to moderate pain, prophylaxis of MI.
Side effects/Nursing considerations: chew before swallowing, may cause GI bleeding, epigastric distress, laryngeal edema, anemia, hemolysis. Avoid concurrent
use of alcohol, teach that if tablets smell like vinegar to dispose of them.

Name Atorvastatin Concentration Dosage Amount 80 mg

Route PO Frequency QHS
Pharmaceutical class: HMG COA reductase inhibitors Home Hospital or Both
Indication: adjunctive management of primary hypercholesterolemia and mixed dyslipidemia.
Side effects/Nursing considerations: rhabdomyolysis, rashes, diarrhea, abd cramps, angioneurotic edema, rhinitis. Teach patient that if they develop muscle
tenderness to tell their doctor immediately as this may indicate rhabdomyolysis. Monitor LFTs.

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\

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Side effects/Nursing considerations

Name Famotidine Concentration Dosage Amount 20mg

Route IV Frequency BID
Pharmaceutical class: Histamine H2 antagonists Home Hospital or Both
Indication: management of GERD. Tx of heartburn, acid indigestion and sour stomach.
Side effects/Nursing considerations: dilute w/0.9% NaCl into 5ml, give over 2min. May cause arrhythmias, aplastic anemia, agranulocytosis, constipation,
dizziness, drowsiness. Monitor CBCs, assess for confusion, teach about checking for blood in stool, avoid alcohol and NSAIDS while taking, report tarry black
stools, erver, sore throat, diarrhea etc.

Name Metoprolol Concentration Dosage Amount 25mg

Route PO Frequency BID

Pharmaceutical class: beta blocker Home Hospital or Both
Indication: angina pectoris, HTN, prevention of MI, management of stable symptomatic Heart failure.
Side effects/Nursing considerations: may cause fatigue, weakness, orthostatic hypotension, bradycardia, HF, pulmonary edema. Patient teaching: get up slowly
as this medication may cause orthostatic hypotension, monitor blood sugar levels especially if diabetic as this medication may mask symptoms of hypoglycemia,
check heart rate and blood pressure before giving if below 100 systolic, or 60 bpm do not take.

Name Heparin Concentration 25,000units/500ml Dosage Amount 950units/hour

Route IV D5W Infusion Frequency Continuous
Pharmaceutical class: antithrombotics Home Hospital or Both
Indication: prophylaxis and tx of various thromboembolic disorders.
Side effects/Nursing considerations: bleeding, heparin induced thrombocytopenia, anemia. Patient teaching: assess for signs of bleeding and hemorrhage-
bleeding gums, nosebleed, tarry stools, unusual bruising, hematuria. Monitor platelet and H&H levels.

Name Nitroglycerin Concentration 25mg/250ml Dosage Amount 250ml

Route IV Frequency Continuous

Pharmaceutical class: nitrates Home Hospital or Both
Indication: acute and long term prophylactic management of angina pectoris. Adjunct tx of HF, adjunct tx of AMI.
Side effects/Nursing considerations: dizziness, HA, hypotension, tachycardia, syncope. Monitor BP and pulse before and after administration. Hold if BP systolic
is less than 100 and if pulse is less than 60, would want to teach patient this as well. Give one every five minutes up to 3, check pain after each to see if it goes
away if so stop, or if un-relieved and what is pain level.

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Side effects/Nursing considerations

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Side effects/Nursing considerations

Name Concentration Dosage Amount

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Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Side effects/Nursing considerations

Name Concentration Dosage Amount

Route Frequency
Pharmaceutical class Home Hospital or Both
Indication
Side effects/Nursing considerations

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Diet pt follows at home? No specific diet
24 HR average home diet:
Breakfast: None, just a cup of coffee
Lunch: None, if any An orange
Analysis of home diet (Compare to My Plate and
Consider co-morbidities and cultural considerations):
According to the superfood tracker on choosemyplate.gov
The patient eats below her daily percentage of what she
should be eating. Her protein percentage is 52 percent of
what she should be eating, dairy 4% of what she should be
eating, refined grains 15% of what she should be,
vegetables are 60% and fruits are 36% of what she should
be eating.
She consumes 640 calories a day, and eats 77 empty
calories. This is all based on a 2000 calorie diet.

Dinner: Mashed potatoes and some type of a meat

Snacks: Potato chips and dip, Fritos.

Liquids (include alcohol): Coffee (in morning),

H2O (in afternoon), and beer (on weekends).
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Takes care of self, and husband will help out.
How do you generally cope with stress? or What do you do when you are upset?
walk away, yell, drink, smoke.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
None, other than some anxiety currently.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? ________________yes, first husband______________________

Have you ever been talked down to?______Yes_____ Have you ever been hit punched or slapped? ____Yes____
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Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__________yes________________________ If yes, have you sought help for this? _______yes__________

Are you currently in a safe relationship? absolutely.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
According to Treas and Wilkinson (2014), The goal of this stage is to be creative and productive. Often this is
accomplished through work or relationships, such as raising healthy, functional children or contributing to society by
developing a distinguished career, for example in nursing. The person who fails to achieve generativity (the desire and
motivation to guide the next generation) may manifest stagnation in the form of superficial relationships and self-
absorption. Simply having children does not guarantee generativity.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is in the generativity stage of Eriksons stages of psychosocial development. She is very productive especially
with a lower level of education and what her job entails. Not to mention she has a family and has raised a family of
children and grandchildren. She understands what has gone on in life and is looking forward to her future and talked about
the accomplishments of her children as well as grandchildren.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I do not think it currently has any impact on the developmental stage, however in the future it possibly could impact her.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
smoking and stress

What does your illness mean to you?

wake up call, scary

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record

Have you ever been sexually active?__yes_____________________________________________________________

Do you prefer women, men or both genders? _____men___________________________________________________
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? _____________yes___________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? _______________none______________

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How long have you been with your current partner?_______20 years about___________________________________

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

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_Its important_________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
___No______________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? Cigarettes How much?(specify daily amount) For how many years? 42 years
pack a day (age 16 thru current )

If applicable, when did the

Pack Years: 21
patient quit?

Does anyone in the patients household smoke tobacco? If

Has the patient ever tried to quit? Yes, couple of times
so, what, and how much? Yes, husband, pack of cigarettes.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Beer, 55 select How much? (give specific volume) For how many years?
7 or 8 (on the weekends, Fri. or Sat.) (age 16 thru current )

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Marijuana, PCP, coke, speed. How much? For how many years?
just tried them (age thru )
Back in the 70s
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No
Only tried them.

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

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 10 REVIEW OF SYSTEMS
General Constitution Gastrointestinal Immunologic
Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen No SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: every other day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Normal frequency of urination: could not
Post-nasal drip Other:
recall x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth once x/day Diabetes Type:
Routine dentist visits None x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Unkown Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? 50 Meningitis
Other: Date of last Mammogram &Result: unk. Other:
Date of DEXA Bone Density & Result:
Unkown
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 10/25 Arthritis Chicken Pox

University of South Florida College of Nursing Revision August 2013 10

Other: Other: Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

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

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10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)
General Survey: Patient upon Height:154.9 cm Weight:87.5kg BMI: Pain: (include rating & location)
entry of room appears relaxed, Pulse: 69 0
Blood
is resting in bed speaking with Pressure: 102/50 (62), left arm
husband. (include location)
Temperature: (route taken?) Respirations: 18
99.4 Oral SpO2 97% Is the patient on Room Air or O2:O2, 2L NC
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]

awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

Peripheral IV site Type: 20ga Location: RFA Date inserted: 10/25/2015

no redness, edema, or discharge
Fluids infusing? no yes - what? Heparin and Nitro drip
Peripheral IV site Type: Location: Date inserted:
no redness, edema, or discharge
Fluids infusing? no yes - what?
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?

HEENT: Facial features symmetric No pain in sinus region No pain, clicking of TMJ Trachea midline
Thyroid not enlarged No palpable lymph nodes sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

University of South Florida College of Nursing Revision August 2013 12

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes Sputum production: thick thin Amount: scant small moderate large
CR - Crackles Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi Clear sputum
D Diminished
S Stridor Wheezing noted bibasilar.
Ab - Absent

Cardiovascular: No lifts, heaves, or thrills PMI felt at:

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

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 3 Radial: 3 Femoral Popliteal: 3 DP: 3 PT:3
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

GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Urine output: Clear Cloudy Color: Yellow Previous 24 hour output: mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 26 / 2015 ) Formed Semi-formed Unformed Soft Hard Liquid Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Hemoccult positive / negative (leave blank if not done)
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:
Musculoskeletal: Full ROM intact in all extremities without crepitus
 Strength bilaterally equal at _5___ RUE _5___ LUE _5__ RLE & __5__ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration 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: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

Troponin Troponin has an upward Worry would be an MI,
0.04 10/25/2015 21:02 trend then goes back also would check renal
5.58 H 10/26/2015 02:07 down. function, renal panel is all
8.04 H 10/26/2015 04:41 within normal limits.
2.62 H 10/27/2015 03:38 There is a hx of MI on her
Normal 0.00-0.08 ng/mL ECG, but she has no
recollection of a previous
MI.
WBC White bloods cells Clearly no infection
9.6 10/25/2015 21:03 elevate slightly but still fighting is going on that is
10.3 10/27/2015 03:38 within normal limits. suspected.
Normal: 4.5-11.0
RBC There is a downward She appears to have lost
4.06 10/25/2015 21:03 trend on RBC count. RBCs, patient did
3.37 L 10/27/2015 03:38 receive a blood
Normal: 4.0-5.20 transfusion.
HGB There is a downward Hemoglobin is low will
11.3 L 10/25/2015 21:03 trend on HGB levels. want to monitor it for
9.9 L 10/27/2015 03:38 getting any lower may
Normal: 12.3-15.3 need a transfusion.
HCT There is a downward Hematocrit is low would
34.9 L 10/25/2015 21:03 trend on HCT levels. want to report to
30.3 L 10/27/2015 03:38 physician to see if
Normal: 35.0-47.0 anything should be done.
Platelets Slight downward trend Patients platelets within
205 WNL 10/25/2015 21:03 but platelets are still normal limits.
191 WNL 10/27/2015 03:38 within normal limits.
 Normal: 150-400
Glucose Trend is downward. Elevated glucose levels
148 H 10/25/2015 21:03 will want to check sugars
118 H 10/26/2015 08:07 regularly and patient
119 H 10/27/2015 03:38 educate.
Normal: 70-100 mg/dL
Uric Acid No trend can be made Elevated uric acid,
6.1 H 10/26/2015 08:07 currently. potentially a gout flare
Normal: 2.4-5.7 mg/dL up.
HDL Downward trend. With HDL going down
41 L 10/26/2015 08:07 will want to worry about
33 L 10/27/2015 03:38 cholesterol problems
Normal: 45-86 mg/dL
LDL Downward trend. The levels are still within
168 WNL 10/26/2015 08:07 normal limits.
126 WNL 10/27/2015 03:38
Normal:
D-Dimer Elevated d-dimer but no D-dimer is indicative of
0.60 H 10/25/2015 21:03 trend can be made. clots so could think there
Normal: 0.00-0.50 ug/mL may be clots.
LFEU
C-Reactive Protein Cannot make a trend at There is most likely some
0.6 H 10/26/2015 08:07 the moment. sort of inflammation
Normal: 0.0-0.4 mg/dL going on in her body.
INR Cannot make a trend at INR within normal limits
0.96 WNL 10/26/2015 10:21 the moment. for a patient not on
Normal: 0.81-1.20 Coumadin or warfarin.
PTTH PTTH has an upward Patient is on a heparin
32.1 WNL 10/26/2015 17:04 trend. drip which could explain
55.0 H 10/27/2015 03:38 for the elevated PTTH,
Normal 22.9-36.3 sec would want to report the
level.
Hemoglobin A1C No trend can be made at Pt is within at risk range
5.7 10/26/2015 17:04 this time. for diabetes.
At Risk:5.7-6.4

Had multiple ECGs, was in sinus tachycardia but then was no longer in it, has biatrial enlargement and an
anterior infarct, old, age indeterminate. Chest xray- no acute pulmonary process. A lung ventilation/perfusion
scan was done for chest pain and elevated d-dimer, the impression was there is a low probability of a PE.
Echocardiogram impression-left ventricle EF between 30-35%, grade 1 diastolic dysfunction. Mitral leafelet
thickening, mild mitral annular calcification, mild mitral valve regurgitation. Inferior vena cava collapses greater
than 50% with inspiration.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Q4H vitals per hospital protocol. Q4H assessments per hospital protocol. NPO diet, pre-procedure.
O2, 2L NC.

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

1. Decreased cardiac output related to altered heart rate, altered stroke volume, as evidenced by ejection fraction of 30-35%,
little activity tolerance.

2. Risk for bleeding as evidenced by heparin drip, hemoglobin count.

3. Risk for unstable blood glucose as evidenced by hemoglobin A1C of 5.7, elevated blood glucose levels.

4.

5.
 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output related to altered heart rate, altered stroke volume, as evidenced by ejection fraction of 30-35%, little activity
tolerance.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day care is
Goal Provide References Provided
Will demonstrate adequate cardiac Recognize primary characteristics These are s/s of decreased cardiac Patient was educated on skin color
output as evidenced by blood of decreased cardiac output as output and we can educate the changes and cool skin and to report
pressure, pulse rate and rhythm fatigue, dyspnea, edema, patient on these as they are things chest pain if new onset.
within normal parameters for orthopnea, paroxysmal nocturnal we want them to know with a
patient; strong peripheral pulses; dyspnea, and increased central decreased cardiac output.
maintained level of mentation; lack venous pressure. Recognize
of chest discomfort or dyspnea, and secondary characteristics of
adequate urine output; an ability to decreased cardiac output as weight
tolerate activity without symptoms gain, hepatomegaly, JVD,
of dyspnea, syncope or chest pain. palpitations, lung crackles,
oliguria, coughing, clammy skin,
and skin color changes.

Remain free of side effects from
the medications used to achieve
adequate cardiac output this shift.
Monitor and report presence and These are signs and symptoms of No new signs and symptoms of
degree of symptoms including HF and decreased cardiac output so decreased cardiac output were
dyspnea at rest or with reduced they are things we will want to noticed during shift.
exercise capacity, orthopnea, PND, monitor during our shift.
nocturnal cough, distended
abdomen, fatigue or weakness. As
well as signs of JVD, S3 gallop,
rales, positive hepato-jugular
reflux, ascites, laterally displaced
or pronounced PMI, heart murmurs
narrow pulse pressure, cool
extremities, tachycardia, and
irregular heartbeat.

Will explain actions and Apply compression stockings or These are all things as a nurse we Patient did not have any chest pain,
precautions to prevent primary or SCDs, check blood pressure pulse want to be checking and doing with SCDs were in place, labs were
secondary cardiac disease. and condition before administering a patient that has a decreased checked as they came in, no ECG
 medications, observe for and report cardiac output to ensure health and changes noted, pulse and blood
chest pain, watch lab data, monitor checking for any changes that may pressure checked before and
ECG changes. be an issue. shortly after given cardiac
medications.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
***F/U appts
***Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
 15 CARE PLAN
Nursing Diagnosis: Risk for bleeding as evidenced by heparin drip, hemoglobin count.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Interventions on
Goal Provide References Day care is Provided
Will discuss precautions to prevent Monitor for hemorrhage especially Signs of bleeding or hemorrhage No signs of bleeding or
bleeding complications this shift. in those at risk for bleeding. Watch may indicate blood is too thin and hemorrhage we noted this shift.
for any signs of bleeding. we should contact provider.

Will explain actions that should be
taken if bleeding happens this shift.
If bleeding does develop, apply
pressure over site as needed or
appropriate, on the appropriate
pressure site over an artery, and use
pressure dressings as needed.
Education on what to do if
bleeding does occur is key to
prevent major blood loss. AS well
as acting and applying pressure
may prevent more blood loss.
Patient was educated on this when
taking out an IV site, explained
why holding pressure and why it is
important especially to a patient
with a risk of bleeding.

Will monitor for signs and Monitor all medications for Monitoring medications for an Medications were monitored
symptoms of bleeding this shift. thepotential to increase bleeding increased potential of bleeding will patient is on a heparin drip and labs
such as aspirin, NSAIDS, SSRIs. be key in aiding to prevention of were run as needed and drip
hemorrhage. adjusted as needed.

Will maintain a MAP above 70, a
HR between 60 and 100, with a
normal rhythm this shift.
Assess vital signs at frequent
intervals to assess for physiological
evidence of bleeding such as
tachycardia, tachypnea, and
hypotension. Symptoms may
include dizziness, shortness of
breath, and fatigue.
Assessing vitals are key as they can Patients vital signs were within
be a quick sign of bleeding normal limits this shift.
occurring whereas external signs
may be later on in the hemorrhage
process.

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

15 CARE PLAN
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Interventions on
Goal Provide References Day care is Provided

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

Ackley, B. & Ladwig, G. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care
(Tenth ed. Pp. 353-356 & 575-583). Maryland Heights, Missouri: Mosby, an imprint of Elsevier

ChooseMyPlate.gov (2011). SuperTracker. Retrieved from http://www.choosemyplate.gov/supertracker-

tools/supertracker.html

Huether, S., McCance, K. (2008). Understanding Pathophysiology. (Fifth Ed. Pp. 604-609). St. Louis, Missouri:
Elsevier, Mosby.

Treas, L., & Wilkinson, J. (2014). Basic Nursing: Concepts, skills & reasoning. Philadelphia, Pennsylvania:
F.A. Davis Company.

Unbound Medicine, Inc. (2015). Daviss drug guide (Version1.17). [Mobile application software]. Retrieved
from https://itunes.apple.com/us/app/daviss-drug-guide-updates/id301427093?mt=8