Professional Documents
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COLLEGE OF NURSING
Student: Jeanne Zamith
Assignment Date: 03/02/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
1 PATIENT INFORMATION
Patient Initials: GH Age: 82 Admission Date: 03/02/2017
Gender: M Marital Status: Married Primary Medical Diagnosis: CHF
Primary Language: English
Level of Education: High School graduate Other Medical Diagnoses: (new on this admission)
Internal hemorrhoids
Occupation (if retired, what from?): Retired; construction and military Number/ages children/siblings: Children: 1
daughter; age 53 & 1 sister: Died at age 78
Served/Veteran: Yes Code Status: Full resuscitation
If yes: Ever deployed? Yes; Korean War
Living Arrangements: Living with wife in a one-story home. Advanced Directives: Wife
Culture/ Ethnicity /Nationality: Caucasian Surgery Date: None
Procedure: Bleeding screen
Religion: Baptist Type of Insurance: Medicare
1 CHIEF COMPLAINT:
Patient stated that his stool looked like blueberry jello and progressively became redder throughout the day.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCARTS the symptoms in addition to the hospital course
of stay)
Patient is an 82-year-old white male admitted to the Emergency Department on Wednesday, March 1 at 1753 as
result of a gastrointestinal bleed that began at around 1100 that morning. According to the patient and his wife, the
stool looked like blueberry Jell-O clots and then advanced to bright red stool as the day progressed. Patient stated
nothing made the bleeding worse or better, which is why [I] decided to come to the emergency room. Patient
denies any previous history of GI bleeding and denied having any pain associated with the bleeding. Patient was
discharged two days ago, 02/27, from a COPD exacerbation and was readmitted yesterday for another cause.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1983 HTN: No hospitalizations; carvedilol prescribed
1993 COPD: 4 hospitalizations for exacerbations; breathing treatment (Atrovent and predisone) prescribed;
PCP advised smoking cessation
06/2009 Lung cancer: CyberKnife treatment used
02/2013 CHF: Multiple hospitalizations; furosemide prescribed (along with continuing carvedilol for HTN)
04/2014 Atrial Fibrillation: No hospitalizations; No pharmacologic intervention
Stomach Ulcers
Environmental
Mental Health
Age (in years)
FAMILY
Heart Trouble
Bleeds Easily
Hypertension
Cause
Alcoholism
MEDICAL
Glaucoma
Problems
Problems
Allergies
of
Diabetes
Arthritis
Seizures
Anemia
Asthma
Kidney
HISTORY
Cancer
Tumor
Stroke
Death
Gout
(if
applicable)
Father 77 MI
Mother 81 CHF
Sister 78 CHF
Comments: Include age of onset
Father: Patient was unable to recall the onset of his fathers medical conditions.
Mother: Patient was unable to recall the onset of his mothers medical conditions.
Sister: Patient stated that his sisters heart issues began shortly after his.
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) U
Adult Tetanus (Date) Is within 10 years? 02/29/2017
Influenza (flu) (Date) Is within 1 years? 08/31/2016
Pneumococcal (pneumonia) (Date) Is within 5 years? 02/29/2017
Have you had any other vaccines given for international travel or
occupational purposes?
1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Levaquin Joint swelling and trouble walking
Amlodipine Edema
Medications/other Compazine Confused and combative
Penicillin SOB and urticaria
Sensitive to tape Patients skin tears
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 Treas and Wilkinson (2010), heart failure is defined as a loss or dysfunction of the cardiac muscle, causing the
ventricles to become unable to fill or eject blood, thus, making the heart unable to supply the bodys metabolic needs. This chronic
condition causes heart failure patients to present with inability to tolerate activities, fluid retention, and fatigue. The most common
causes of heart failure include hypertension, coronary artery disease, and dilated cardiomyopathies. Other risk factors include
environmental exposure, age, obesity, sedentary lifestyle, diabetes, hyperlipidemia, and smoking. Two different processes may lead to
heart failure, systolic and diastolic dysfunction. Both may occur simultaneously and can result in similar symptoms. Systolic
dysfunction is characterized by volume overload and decreased contractility (Treas & Wilkinson, 2014). Once this occurs, the heart
is no longer able to eject enough blood to meet the bodys demands, which can lead to right, left, and/or biventricular heart failure.
Diastolic dysfunction is characterized by elevated filling pressures with preserved left ventricular ejection fraction. Once the disease
progresses, it can be known as chronic heart failure. These patients usually present with anorexia, dyspnea, fatigue, nausea, vomiting,
and slow changes in their ability to perform activities of daily living (Treas & Wilkinson, 2014). Assessments may show a confused
patient due to low cardiac output, thus, poor cerebral perfusion. Genetic factors include family members with: CAD, HTN, DM,
sudden cardiac death, cardiomyopathies, or PVD. Though incurable, pharmacologic management has been shown to have clear
benefits both in prognosis and quality of life. Treatment for heart failure includes: alleviating symptoms, improving perfusion,
increasing activity tolerance, improving quality of life, and minimizing risk factors. Medications such as ACE-Inhibitors, ARBs, Beta-
Blockers, Diuretics, Aldosterone Antagonists, Antiarrhythmic agents, anticoagulant agents, and inotropic agents are combined to
University of South Florida College of Nursing Revision September 2014 2
create a regimen, providing the best quality of life possible. Implantable cardioverter defibrillators are also available for later stages of
the disease process. Heart failure follows a predictable course; patients usually start with stable symptoms and then progress to
episodes of exacerbations, which leave the patient unable to regain the same functional stability as prior. These exacerbations become
more common over time, usually making stabilization difficult and eventually leading to death (Treas & Wilkinson, 2010).
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and
PRN medication. Give trade and generic name.]
Name: ipratropium (Atrovent) Concentration: 500 mcg Dosage Amount: 500 mcg
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
My bride
How do you generally cope with stress? or What do you do when you are upset?
Patient stated I generally dont really get all that stressed. When hes upset, patient stated I just go to my wife, and she
knocks some sense into me.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient stated that his wife was recently diagnosed with an aneurysm between her heart and lung and the doctor said it
could rupture any minute, killing her instantly.
4 DEVELOPMENTAL CONSIDERATIONS:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
GH is an 82 year old male, so the ego integrity vs despair stage would be most appropriate. The patient showed more
signs of the ego integrity stage rather than despair. He was not showing a sense of loss, discomfort with life and aging,
and fear of death, usually associated with the despair stage (Treas & Wilkinson, 2014). The patient seems to have few
regrets and understands that he is close to the end of his life.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patient states that he knows he is close to passing away but still wants to travel more and spend more time
outside, but his condition limits his mobility and ability to do the things he wants to in his last days. GH believes
this disease has taught him to cherish the moments he has left with his wife and family.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient stated Im just an old man now. Im sure smoking for my whole life had something to do with it, too.
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Have you ever been sexually active? Yes.
Do you prefer women, men or both genders? Patient has a wife.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? N/A
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? Only when my wife lets me be.
If yes, are you in a monogamous relationship? Yes, for almost 70 years.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or
an unintended pregnancy? Patient claims he does not prevent acquiring an STD, but he is in a monogamous
relationship.
How long have you been with your current partner? 70 years
Have any medical or surgical conditions changed your ability to have sexual activity? The patient claimed
that hes afraid of his wifes aneurysm. He also stated his chronic SOB from CHF have changed his sexual
activity.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or
unintended pregnancy? No.
ALCOHOL:
Does the patient drink alcohol or has he/she ever drank alcohol? Yes, patient was an alcoholic for about 15 years.
What? Beer
How much? Patients wife stated she could not keep track of how much he was drinking, especially after he came back
from the Korean War.
For how many years? About 15 years
Frequency? Patient stated he would drink when he was happy or sad, it didnt matter the occasion.
If applicable, when did the patient quit? Patient quit when he was forty years old.
CHEMICAL USE:
Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No
If so, what? Did not ask because patient stated that he had never tried the specified substances.
How much? Did not ask because patient stated that he had never tried the specified substances.
For how many years? Did not ask because patient stated that he had never tried the specified substances.
Is that patient currently using drugs? Did not ask because patient stated that he had never tried the specified
substances.
When did the patient quit? Did not ask because patient stated that he had never tried the specified substances.
Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient stated that he was most likely exposed to hazards/risks when he was fighting overseas. He was also a construction
worker for many years, so he was out in the sun most of the day.
For Veterans: Have you had any kind of service related exposure?
Patient stated that he was exposed to agent orange.
General Constitution
Recent weight loss or gain
How many lbs? I usually lose 3-4 lbs on and off
Time frame? 2 years
Intentional? No
How do you view your overall health? I have a lot of issues.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient also has atrial fibrillation.
Any other questions or comments that your patient would like you to know?
Patient denied having any questions.
10 PHYSICAL EXAMINATION:
General Survey: A & O x3 Height: 6 1 Weight: 212 pounds BMI: 28 Pain (include rating and
Vitals: 03/02 @ 0948 Pulse: 108 110 Blood Pressure: (include location): location): Patient is
03/02 @ 1246 RR: 1818 123/66 124/65 currently in no pain.
Temperature: (route SpO2: 93% 92% Is the patient on Room Air or O2
taken?) 98.2F 98.8F 4L of O2
ORAL
Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?
Comments: Patients skin is fragile and tears easily. Tenting is present. Rashes are present due to the tape. Clubbing is
present due to chronic hypoxia r/t COPD. Capillary refill was 5 seconds. Hair was not present on the legs.
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 4/mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: *Did not assess*
University of South Florida College of Nursing Revision September 2014 8
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Dentures well-kempt
Comments: No comments
Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production; Amount: not being measured
Color: Clear
Lung sounds: Wheezing and crackles present in all regions.
RUL: CR and WH present LUL: CR and WH present
RML: CR and WH present LLL: CR and WH present
RLL: CR and WH present
(CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab Absent)
Comments: Patients respirations were irregular and slightly labored. Unable to determine whether the lungs percussed resonant, but
due to the fluid accumulation, I would assume the sound would be on the dull side.
GU Urine output: Clear Cloudy Color: Pale yellow Previous 24 hour output: N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
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]
University of South Florida College of Nursing Revision September 2014 9
Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: negative Babinski: negative
Patient was unable to get out of bed due to SOB to complete the test for proprioception and the Rombergs test; however,
graphesthesia and stereognosis were intact.
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):
CHF:
1) Excess fluid volume r/t cardiac dysfunction and compromised regulatory mechanism aeb crackles upon
auscultation, +1 peripheral pitting edema, weight gain over a short period of time, blood pressure
changes, and intake exceeding cardiac output.
2) Decreased cardiac output r/t altered heart rate and rhythm aeb EF 35%, diagnosis of CHF, and diagnosis
of atrial fibrillation.
3) Ineffective breathing pattern r/t hypoventilation aeb dyspnea, nasal flaring, orthopnea, and alterations in
depth of breathing.
GI Bleed:
1) Fatigue r/t loss of circulating blood volume aeb coffee-ground stools that proceeded to bright red stools,
verbalization of lack of energy, and drowsiness.
15 CARE PLAN
Nursing Diagnosis: Excess fluid volume r/t cardiac dysfunction and compromised regulatory mechanism aeb
crackles upon auscultation, +1 peripheral pitting edema, weight gain over a short period of time, blood pressure
changes, and intake exceeding cardiac output (Ackley, 2007).
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 appointments: PCP and Dr. Saco (GI specialist)
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Ackley, B. J., Ladwig, G. B., & Elsevier, c2008. (2007). Nursing diagnosis handbook: An Evidence
Choose MyPlate. (2016, January 12). Retrieved October 26, 2016, from Choose MyPlate,
https://www.choosemyplate.gov/
Commane, D. (2009). Diet, Ageing and Genetic Factors in the pathogenesis of diverticular
Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical Surgical Nursing: Preparation for
Pai, R. K., & Fort, S. (2014). Laboratory tests for heart failure. Retrieved from:
http://www.uofmhealth.org/health-library/hw41813
Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills, and Reasoning. Philadelphia,