‫بسم الله الرحمن الرحيم‬

CRITICAL CARE RESPONSE PATTERN ASSESSMENT TOOL

Name of patient : Z.A.H Age: 60years Sex : Male
Address: Nablus
Date of admission: 12/2/2014
Medical Diagnosis :pre-op (I.H.D) & HTN &unstable angina & DM
type 2as written on his fail .
Reason for admission: The patient came to the hospital to works for his coronary
artery bypass graft(elective CABG)
Allergies::no allergy from any type of food .no allergy from medication.

COMMUNICATING –
A pattern involving sending messages Nursing Diagnosis
Read, write, and understand English (circle): Patient can write, read, for
both Arabic and English. but not good in English just a
little.

Altered communication: No any Barriers to communication, no

physical barriers like noise, no gender barrier (patient
accept to talk with me freely without any problems), no
language barrier (we use Arabic language), and no
Cultural barrier. I communicate with patient orally nothing
impair his ability to speak like mechanical ventilator.

Other language: no Verbal Impaired :no

Barriers to communication : he didn't have any barrier .
Alternate form of communication: Yes alternate form of
communication like
facial expression when feel pain.

KNOWING - A pattern involving the meaning associated with information

Current health problems: yes…the patient knows about his current health he has
sufficient information (why he in hospital , what's the causes of his disease , he
knows the purpose of surgical , he know information about medication that he use
but not deeply ).
Previous illnesses/hospitalizations/surgeries :he free from Previous
illnesses/hospitalizations/surgeries (this time the time he
admitted to hospital )

History of the following problems:

Heart : No history of atherosclerosis… coronary artery disease… peripheral artery
disease… heart failure… cardiomyopathy… endocarditic… myocarditis….. pericarditis
myocardial infarction …. arrhythmias …and valve disease.

Peripheral vascular: No history of Varicose Veins, Deep Vein Thrombosis (DVT) , vasculitis,
Reynaud's disease.

Lung : No history of Chronic obstructive pulmonary disease (COPD) ,Upper respiratory tract
infection , Lower respiratory tract infection (pneumonia, tuberculosis), and pleural effusion .

Liver : No history of liver disease like liver cirrhosis.

kidney :. : No history of renal disease like renal failure .

Cerebrovascular: No history of transient ischemic attack (TIA) ,or Hemorrhagic Stroke.
Rheumatic fever .

Thyroid: No Hypothyroidism & Hyperthyroidism.

Drug abuse: No history of drug abuse

Recent history of the following: Nursing diagnosis

Blood transfusion: no Trauma: none CO poisoning :none
Heart stroke: none Sepsis: none Muscle injury: yes
Nephrotoxic medications: none
Current medication in hospital use concor & aldactone & clexan &tritac.
……………………………………………………………………………….
Risk factors Present perceptions/knowledge of

1.Hypertension: yes he know what HTN mean….. So he take his

medication regularly, He doesn’t smoke, and he avoid high fat diet as he said.

2.Hyperlipidemia : No he know about it .

 3.Smoking: No he said smoking cause many problem
especially heart disease so he doesn’t smoke.

4. Obesity: No he control his weight very well. Because he

has DM and obesity not good for his health as he said.

5. Diabetes yes he has very good knowledge about DM.

6. Sedentary living yes he doesn’t do activity since he make surgery but he

know must make activity.

7. Stress : yes he say that stress is significantly affect health as he

said elevated stress level elevate blood pressure.
8. Alcohol use No

9. Oral contraceptives No

10. Family history free No history of Heart disease….Peripheral

vascular disease… lung disease… cerebrovascular disease.

Perception/knowledge of illness/test/surgery ……yes pt has a perception and

knowledge of his illness .

Expectations of therapy :
Pt has brief knowledge of his expectation of therapy.

Misconceptions: no any Misconceptions

Readiness to learn: . yes he ready to learn anything at any time…. he received

information very well.

Requests information concerning: yes he Request information about anything related

to his condition .
Educational level : pt educational level is 10th grad.

Learning impeded by: nothing impeded his learning … but sometime pain .

Orientation : Nursing diagnosis

Level of alertness: patient is alert, conscious, and oriented & galso scoma
scale is 15\15
Altered thought process :none, patient has good thought process

Orientation: Person :yes Place: yes Time: yes

Appropriate behavior /communication: patient has appropriate behavior and

.communication & quite and lessening for the instruction
.
Memory
Memory intact: Yes ……… Recent: yes Remote yes…………
But when talk with you I notice he was consentrate on past event.

VALUING----- A pattern involving the assessment of relative worth

Religious preference : The patient is Muslim.
Important religious practices: Fasting ….prying and reading holly Quraan

Spiritual concerns: He knows what the disease… which he suffered & his surgery that
he do it and which accommodates the lifestyle experienced in this stage after operation

Cultural orientation : yes he is oriented to the culture he lives in ,the nature of the
society he live in.
Cultural practices::he participate in group activities and events with people.

RELATING -A pattern involving establishing bonds

Role
Marital status : He is married.

Age and health of significant other: his wife age 57 years.

Parenting : his wife.
……………………
Sexual dysfunction :I don’t asked pt .but I thing(: pt has sexual dysfunction due to
decrease in sexual desire related to his age.

Number of children :::he have 2girle &3 boys ……………. Ages:…his ages
respectively : 46....42....40.....37..33.. years as he said .
Role in home : He was supporting his wife in house work such as (cleaning , ere the
field and trim trees).
Financial support : by himself (Works with the wife of his son in a dental clinic
because he has experience in this field and has worked it before)….also from sons.

Occupation : Works with the wife of his son in a dental clinic because he has
experience in this field and has worked it before.
Altered Family process
-Job satisfaction /concerns :pt satisfacted from his job because he like it too much.

-Physical/mental energy expenditures: patient has good physical/mental energy

expenditure.

Sexual relationship satisfactory/ unsatisfactory : my opinion that summarize when talk

with pt (patient doesn’t care about his sexual relationship related to decrease in
sexual desire due to his age)

-Sexual partner (s): his wife.

-Physical difficulties/effects of illness related to sex : I don’t ask about this.

Socialization:
Quality of relationships with others:
Patient's description: good social relationship. the patient's visit many friends and
spend his leisure,
Significant other’s description : is good socialized with his family …. friends.. and
neighbors.
Staff observations :the pt is loved by everyone, a lot of people came to visit him& he
has good relationship with teams .the pt cooperative with them.

Verbalize feeling of being alone : No verbalize feeling of being alone .

FEELING- A Pattern involving the subjective awareness of information

Comfort: pt discomfort & feeling bore. Nursing diagnosis : discomfort
&fatigue r\t pain.

Pain/discomfort: Yes
Onset: post operation Duration : continuous
Location :chest(operation site) &extremities Quality: sharp stabbing .

Radiation :back Pained /acute

Aggravating factors : folly’s catheter, operation wound(leg and chest).

Alleviating factors : rest &avoid movement and sleep on the other his back.

Objective manifestations: patient seems in pain by verbal and nonverbal(facial

expression).& difficulty in movement related to surgery.

Emotional Integrity/States
Recent Stressful life events : Patient concerning about his status after surgery.

Verbalize feelings of: (Anxiety, Fear, Grieving) he say that he can't sleep at night
Asking always about his status and at what time he will out from hospital and this
pain w many time until relief. (Anxiety)
Source : Complaining of pain ………………….. Fear

Physical manifestations : difficulty in movement related to surgery.

MOVING---- A pattern involving activity

Self-care ( 3)…… .. Self-care deficit 0 = Completely independent
1 = Requires use of equipment or devices
2 = Requires help from another person for assistance, supervision or teaching
3 = Requires help from another person and equipment devices
4 = Dependent does not participate in activity (Feeding)

Specify deficits : he can’t move alone .

Discharge planning needs: he need bathing/hygiene & dressing.

Activity Nursing diagnosis
Limitations of movement (Specify level):

Impaired physical mobility :Pt have impaired mobility.

Braces/casts/splints /traction ….he doesn't have anything of this.
Fracture(s) …no extensive bums…… no … paralysis …no
Amputations.. no
Verbal report of fatigue …yes
Exercise habits …. no
Rest
Sleep/rest pattern : insomnia & decrease hour of sleep.
Sleep pattern disturbance
Sleep aids (pillows, met, food ) :no anything .
Difficulty falling remaining asleep yes
Recreation
Leisure activities … visit friends &your sons .
Social activities :pt is socialy

Activities of daily living

Home Maintenance Management
Size & arrangement of home (stairs, bathroom) ….. 2bathroom &3stairs
Impaired home maintenance management
safety needs …... pt live in second floor.

Home responsibilities::: pt take responsibilities

Health maintenance
Health insurance……he has insurance government
Altered health maintenance …no
Regular physical check-ups … no he don’t make .

PRECEIVING –A pattern involving the reception of information

Self – esteem /body image……………………………….Nursing diagnosis

Perception of self and situation : patient High self-confidence and know for the
operation, and is a believer in God . Altered self- concept ..No Self -esteem
disturbance …No
Description of body structure/function : Patient functioning perfectly but due to
advanced age there is some weakness .But the patient feel good about himself and
his performance.
Effects of illness/surgery on self-concept: Patient felt some frustration about the
operation works and it is the first time to enter the hospital, but his resolve was
strong and capable at adapt to the situation.

Meaningfulness
Verbalizes hopelessness…. No
Verbalizes loss of control …No
Sensory /perception
History of restricted environment …. No
Altered sensory/perception Vision impaired …No Glasses… No
Visual Auditory imparted …. No ….. Hearing aid… No
Auditory Gustatory impaired…No
Tactile impaired…No …
Olfactory impaired … No
Reflexes :Biceps R…yes….. L…yes…… Triceps R…yes… L….yes......
Brachioradialis R. yes..L yes… Knee R yes. L yes
Ankle R yes L yes plantar R yes L yes
Exchanging------A pattern Involving mutual giving and receiving
Circulation Nursing diagnosis
Cerebral
Neurologic changes/symptoms …. No
Seizure activity…No
Pupils Eye Opening
L 3 mm
R 3 mm Spontaneous (4)

Reaction: Fluid volume Deficit:…. No

Best Verbal Best Motor Excess: No

Oriented (5) Obeys commands (6)

Glasgow coma scale total 15/15.

Peripheral
Pulses: A = absent B = bruits D = Doppler

+3 = bounding +2 = palpable +1 = faintly palpable

Carotid R b+3 L b+3
Blood pressure: Lying
R 100/70 L 110/82
A-line reading 100/60
Jugular venous distortion………… R…no …… L …no …… CVP
no
Skin temp 37.2axillary Color……normal.
Capillary refill…2sec………… Clubbing…No…..
Edema… mild
Cardiac
PMI (apical)60 Pacemaker ..no ..
Apical rate & rhythm : rate:60bpm and rhythm is regular

Dysrhythmias…No dysrhythmias

Ventilation
Dyspnea: No

Cough : No

History of respiratory disease: No.

Smoker: No .
Respiratory rate ……16 breath/min
Quality: ….. Normal

Use of oxygen: Yes

Comments: nasal cannula 5 letter

Food / Fluid
Usual
Diet: (type) usual …full diet with hyper protein
Loss of appetite: Yes Increased appetite: No
Nausea: No Vomiting: No
Heartburn /indigestion: No Stomatitis: No
Allergy/food intolerance: No

Mastication/ Swallowing problems: No

Dentures: No
Weight t fluctuation last 6 months……84 kg
Lost…. 11kg
Abdominal distention: No
Current Weight …73kg………... Height: …167cm.
Condition of teeth/gum…good …………………………………..
Diet now : Low sugar and low salt diet.
Intravenous therapy: NO

Comments: N/S 0.45

TOTAL =5350

Elimination Nursing diagnosis

Usual bowel habits: Normal

History of bleeding: No

Usual bladder habits: Normal

Intake/Output balance:
INTAKE =5350 OUTPUT=4630…from pt file
Objective
Use of Assertive devices: No
Intermittent Catheterization: No
Indwelling Cather: Yes
Integumentary:
Allergy to:…… the pt doesn't have any allergy from any medication or food .
Skin color/condition Normal.
Excessive perspiration
No( Pale ,Cyanotic ,Ashen ,Jaundice ,
Lesions ,Bruises , Reddened
Rash ,Dryness ,Scars , Pruritis ).

Presence of wounds/Surgical Incisions: yes

If yes, Location :chest & legs
Tubes: Indwelling catheter just & other tube removed .
Sutures/Clips removed: No

CHOOSING- A pattern involving the selection of alternatives

Coping Nursing diagnosis Patient's
ability to cope :pt make a good coping
Families ability to cope/give support his family have a good coping &give pt
support …………………………………. Impaired adjustment parent's acceptance of
Illness…they accept the illness
Patient's adjustment to illness… patient adjustment with his status.

Judgment Compromised
Decision-making ability + Patient's perspective:

Patient bold and not hesitant, able to make decisions, muslim, attacking lazy and
loves vitality and activity

Family’s perspective: Family works to encourage all doing his job and working them
taking his opinion all the things.

Ability to choose from alternative :yes he have ability

Participation:
Compliance with past/current health care regimen : related to his condition
(HTN&DM)
Willingness to comply with future health care regimen : according to pt , he say yes .
Health - Seeking Behaviors:
Expression of desire to seek higher level of wellness : The patient has the desire to
reach the highest levels of health and wellness ... to come back to his daily life to
love.

Prioritized nursing diagnoses/problem list:

1. Risk for decreased cardiac output may be related to altered myocardial
contractility, secondary to temporary factors, such as ventricular wall surgery.

2. Impaired gas exchange related to trauma of extensive chest surgery .

.Ineffective renal tissue perfusion related to decrease cardiac output .3

4. Risk for infection r /to immunosuppression; invasive procedures &tissue

destruction.
5. Anxiety R\T his disease (his facial expression that guide to anxiety.

Signature:
S.T.N .Mohammad Omar Foqha Date of compilation my case :20/2/2014