TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

ATRIAL FIBRILLATION

BY: KRISIANNE MAE L. FRANCISCO

BSN 4B (GROUP 4)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: __________________________ Age: ________Date of Birth: ______________

Medical Diagnosis: _______________________ Nursing Diagnosis: ________________________
Assessed by: _____________________ Date of Assessment: ______________ Time: _____

Area Assessment Description of Findings & Interpretation

N AbN

General Appearance

Posture

Hygiene/Grooming

Nutrition/Diet

Body Size/Habitus
/ The patient is oversized.

Height:

Weight:

Supply appropriate data:

 IBW: ___________
 BMI: 35.6 / The patient is obese.
 IRS: ____________

Behavior
/ Fatigue, light headedness, and weak.

LOC
Vital Signs

Temperature: ℃

Pulse Rate: 137 bpm

/ Irregular pulse rhythm

Rhythm: irregular

Respiration Rate: 28 bpm

/ Tachypneic

Rhythm:
___________

Blood Pressure: 80/50

mmHg / Hypotensive

Skin
/ The patient is pale due to low blood pressure.

Color

Temperature
/ Cold, clammy skin

Turgor

Texture

Integrity

Unusual Marks

Rashes, Lesions

Pressure sore: Yes ___ No

Site:
___________________

Edema: Yes ____ No ____

Site: _______

Type: _____

Size/Degree: _____
Hair

Texture

Thickness

Color & Distribution

Hygiene Status

Nails

Color & Shape

Hygiene Status

Presence of Clubbing

Head

Shape & Symmetry

Unusual swelling

Cranial bruit

Form No.: TSU-COS-

Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
SF-

Area Assessment Description of Findings & Interpretation

N AbN

Eyes

Size, placement &

alignment

Cornea

Pupils

 Size (mm)
 PERRLA

Visual Acuity

Orbital Bruit

Other Findings:
________________

Ear

Location/Alignment

Pinna, Cannals,
Drums

Hygiene

Discharge and Odor

Hearing Acuity

Tinnitus

Vertigo/Dizziness

Other Findings:
______

Nose

Shape

Symmetry

Patency

Mucosal Integrity

Epistaxis

Sinuses

Other Findings:
______

Lips

Integrity

Symmetry

Color
/ Pale color of the lips.

Other Findings: _

Mouth

Hygiene

Number & Condition of

Teeth

Gums

Mucosal Integrity

Tongue

Tonsils

Palate

Parotid Gland

Hoarseness

Other Findings:

Neck

Carotid Bruit

Neck Veins

Thyroid

Trachea
 Rigidity/Tenderness

Mass/Bruises

Other
Findings:_______

Chest and Lungs

Shape & Symmetry

 Nipple & Areola

 Mass/Lump

 Others:__________

Effectivity Date: June 22,

Form No.: TSU-COS-SF- Revision No.: 00 Page 2 of 6
2016

Area Assessment Description of Findings & Interpretation

N AbN

Chest and Lungs

Breathing

 Spontaneity

 With Ventilator

 With Tracheostomy

 Rhythm
/ Tachypneic

 Depth

 Effort

Use of Accessory Muscles

 a. Intercostals
b. Abdominal
c. Sternocleidomastoid
d. Trapezius

Cough

Sputum Production: Yes __ No:

__

 Amount: _____________
 Consistency: __________
 Color: _______________
 Odor: _______________

Chest X-ray Result

Breath Sound (Specify)

a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus

CTT

Location: __________

Suction: ___________

Water Level: _______

Quality of Drainage:
___________

ABG
 Other Findings:
________________

Heart

History
/ Feeling of flip -flops, skips beat like its banging
against the chest walls.
With Palpitation

Dyspnea / The patient is tachypneic.

Rhythm

Point of Maximal Impulsec(PMI)

(PMI is felt at 5th ICS at apex

of heart) Specify:

a. Heaves
b. Clicks
c. Splitting
d. Thrills
e. Callops
f. Muffles

Presence of Heart Sounds

a. S1
b. S2
c. S3
d. S4

Murmurs

a. Systolic
b. Diastolic

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,

Page 3 of 6
SF- 00 2016
 Area Assessment Description of Findings & Interpretation

N AbN

Abdomen

Diet: ____________________

Mode of Feeding: __________

Shape and Symmetry

Umbilicus Protrusion

Bowel Sound (Indicate Sound)

 LUQ: __________
 RUQ: __________
 LLQ: __________
 RLQ: __________

Abdominal Bruit

Distention

Ascites: Yes: ____ No: ____

Nausea

Vomitus/Hematemesis

Amount: _______________

Consistency: ____________

Color: _________________

Odor: _________________

Frequency: _____________

Drainage Tube

Abdominal Mass
 Abdominal Girth: __________

Other Findings:
________________

Back

 Spine
 Paralumbar

Other Findings:
________________

Genitalia

Symmetry

Presence of Tenderness

Urethral Discharge

Bleeding

Pelvic Pain

LMP: ________________

With Dysuria

With Flank Pain

Nocturia

History of Urinary Stone

History of Impotence

With Urinary Catheter

Urinalysis Finding:
_____________

Peritoneal Dialysis (PD)

a. Date Started
 b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Hemodialysis

Frequency:
________________

Last HD:
__________________

Amount of Fluid Removed:

_____

Next HD:
__________________

Place:
____________________
Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,
Page 4 of 6
SF- 00 2016

Area Assessme Description of Findings & Interpretation

nt

N AbN

Rectal Examination

Anal Inspection

With Hemorrhoids: Yes:__

No:__

Location: ______________
Mass

Last Bowel Movement:

_________

Characteristic of Stool:
__________

Other Findings:
________________

Nodes

Lymphadenopathy

Location

a. Cervical R ___ L ___

b. Axillary
c. Inguinal R ___ L ___

Others ______________

Extremity

Texture

Capillary Refill
/ Capillary refill less than 3 seconds.

Peripheral Pulse (both sides)

 Carotid
 Radial
 Ulna
 Brachial
 Femoral
 Posterior Tibial
 Dorsalis Pedis
  Popliteal

Clubbing of Fingers

Varicosities

Thrombophlebitis

Cyanosis
/ Cyanotic nails and oral mucosa

Joints

 Erythema
 Tenderness
 Deformity
 Swelling

Muscles

 Bulk
 Tone
 Tenderness

Ulcerations

Edema

Other Findings:
________________

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22, Page 5 of 6
SF- 00 2016

Area Assessme Description of Findings & Interpretation

nt

N AbN

Hematopoietic

Easy Bruisability

Excessive Bleeding

Anticoagulants

Bleeding Profile

Anemia

Hematology Report

Other Findings:
________________

Neurology

Assessment of Cranial Nerves

 CN I (Olfactory)
 CN II (Optic)
 CN III (Oculomotor)
 CN IV (Trochlear)
 CN V (Trigeminal)
 CN VI (Abducens)
 CN VII (Facial)
 CN VIII (Vestibulocochlear)
 CN IX (Glossopharyngeal)
 CN X (Vagus)
 CN XI (Spinal Accessory)
 CN XII (Hypoglossal)
 Motor and Posture

Sensory Perception

Reflexes

a. Indicate Type of Reflex______

________________________
b. Pathologic Reflex: Yes__
No__

Other Findings:
_________________

Patient’s ADL

a. Bathing
b. Dressing
c. Elimination
d. Mobility and Movement
e. Nutrition and Feeding

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6

ASSESSMENT
Subjective:
“My heart flip – flops,
skips beats, and feels like
it’s banging against my
chest wall, especially if
I’m carrying stuff up my
stairs or bending down
and I was nauseated, light
– headed, and weak. I had
really fast heartbeat and
felt like I was gasping for
air.” As verbalized by the
client.
Objective:
 GCS: 10
 Irregular heart
rhythm
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
NURSING CARE PLAN
DIAGNOSIS PLANNING
Decreased Cardiac After 5 days of rendering Independent
Output related to altered appropriate nursing
electrical conduction as intervention the patient
evidence by irregular will maintain cardiac
heart rhythm. output as evidenced by
heart rate, blood pressure,
respiratory rate, and level
of consciousness within
normal ranges.
INTERVENTION RATIONALE EVALUATION
After 8 hours of nursing
intervention, the clients
 Monitor vital  to determine verbalized improved fluid
signs regularly. changes in the volume as evidenced by:
patient’s
condition.
- Increased urine
output from 14
 Monitor client’s  To note changes into 19mL/hr
intake and output. in renal status.
- Decreased pitting
edema from grade
 Assess ECG 2+ into grade 1+
changes such as  To monitor bipedal edema.
widening of the reoccurrence of
QRS, - Increased blood
arrythmias
prolongation of pressure from
the QT interval, 76/44 into 80/60
increased heart mmHg
rate.
- Normal
respiratory rate 20
  Chest pain  Demonstrate and bpm
encourage use of
Vital Signs: stress  Promotes patient
management participation in
 Temperature: 36.1 behaviors, exerting some
℃ relaxation
sense of control in
 Pulse Rate: 137 techniques,
guided imagery, a stressful
cpm situation.
slow/deep
 Respiration Rate: breathing.
23bpm

 Blood Pressure:  Maintain quiet,

80/50 mmHg comfortable
 For the relaxation
environment.
Laboratory Results: of patient
Restrict visitors as
ECG: necessary.

- No visible P Dependent
waves
 Assist in
- Wide QRS with cardioversion
right bundle  To manage
branch block articular
pattern. fibrillation.
 Provide oxygen
therapy as
indicated.

 Oxygen is
administered to
 increase the
amount of oxygen
carried by
available
 Insert and hemoglobin in the
maintain blood.
intravenous
access.

 Patent access line

may be required
for administration
of emergency
 Administer drugs.
medications as
prescribed.

 Medication
therapy is more
effective when
initiated early.
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SOAPIE CHARTING

S - “My heart flip – flops, skips beats, and feels like it’s banging against my chest wall,
especially if I’m carrying stuff up my stairs or bending down and I was nauseated, light –
headed, and weak. I had really fast heartbeat and felt like I was gasping for air.” As verbalized
by the client.

O-
GCS: 10
Irregular heart rhythm
Chest pain
Vital Signs:
Temperature: 36.1 ℃
Pulse Rate: 137 cpm
Respiration Rate: 23bpm
Blood Pressure: 80/50 mmHg
Laboratory Results:
ECG:
No visible P waves
Wide QRS with right bundle branch block pattern.

A - Decreased Cardiac Output related to altered electrical conduction as evidence by irregular

heart rhythm.
P - After 5 days of rendering appropriate nursing intervention the patient will maintain cardiac
output as evidenced by heart rate, blood pressure, respiratory rate, and level of consciousness
within normal ranges.
I
 Done monitoring vital signs regularly.
 Done monitoring client’s intake and output.
 Done assessing and monitoring ECG changes such as widening of the QRS, prolongation
of the QT interval, increased heart rate.
  Demonstrated and encouraged use of stress management behaviors, relaxation
techniques, guided imagery, slow/deep breathing.
 Maintained quiet, comfortable environment. Restrict visitors as necessary.
 Assisted in cardioversion
 Provided oxygen therapy as indicated.
 Inserted and maintained intravenous access.
 Administered medications as prescribed.
E - After 5 days of rendering appropriate nursing intervention the patient maintained cardiac
output as evidenced by heart rate, blood pressure, respiratory rate, and level of consciousness
within normal ranges.
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

PATIENT EDUCATION FORM

Name Francisco, Krisianne Mae L. Area

Inclusive
Year Level RLE Group dates of
Rotation

Name of
Patien B Age 75 y/o Gender Male
Patient

Date Decreased Cardiac Output related to altered

Diagnosis
Admitted electrical conduction

MAIN CONCEPT / TOPIC:

Details of Patient Education Content:

FAMILY HEALTH TEACHING

- Encourage the client to rest as much as possible reduced doing

extraneous activities.

- Limit food intake and avoid salty, fatty, and high sugar level
foods.

- Encourage healthy lifestyle such as eating fruits and vegetables

good for the heart.

- Drink adequate amount of water every day.

 - Refrain from drinking alcohol and do not smoke.

- Explain the right way and be compliant in taking medications.

- Demonstrate and explain the cardiopulmonary resuscitation.

Patient’s Signature / Significant Other’s Signature

Date Signed

Date Submitted
 NAME OF DRUG MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME:   Control ventricular Dizziness, headache,
Digoxin Inhibits response rate in diarrhea, rash, visual Baseline assessment
sodium/potassium patients with disturbances. Assess apical pulse. If pulse is 60 or less/min
BRAND NAME: ATPase pump in chronic atrial (70 or less/min for children), withhold drug,
Lanoxin myocardial cells. fibrillation. contact physician. Blood samples are best
Promotes calcium taken 6–8 hrs. after dose or just before next
influx. Increases dose.
CLASSIFICATION: effective refractory Intervention/evaluation
Cardiac glycoside, period/decreases Monitor pulse for bradycardia, EKG for
Antiarrhythmic conduction velocity, arrhythmias for 1–2 hrs after administration
decreases heart rate. (excessive slowing of pulse may be first
clinical sign of toxicity). Assess for GI
disturbances, neurologic abnormalities (signs
of toxicity) q2–4h during loading dose (daily
during maintenance). Monitor serum
potassium, magnesium, calcium, renal
function. Therapeutic serum level: 0.8–2
ng/mL; toxic serum level: greater than 2
ng/mL
 NAME OF DRUG MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME:   treatment of Occasional: GI
Warfarin Interferes with hepatic thromboembolic distress (nausea, Baseline assessment
synthesis of vitamin disorders and anorexia, abdominal Cross-check dose with co-worker. Obtain
BRAND NAME: K–dependent clotting embolic cramps, diarrhea). CBC, PT/INR before administration and daily
Coumadin factors, resulting in complications Rare: following therapy initiation. When
depletion of coagulation arising from atrial Hypersensitivity stabilized, follow with INR determination
factors II, VII, IX, X. fibrillation reaction (dermatitis, q4–6wks. Obtain genotyping prior to
CLASSIFICATION: Prevents further urticaria), esp. in those initiating therapy if available. Screen for
Anticoagulant extension of formed sensitive to aspirin. major active bleeding. Question recent history
existing clot; prevents of bleeding, recent trauma, surgical
new clot formation, procedures, epidural anesthesia.
secondary
thromboembolic Intervention/evaluation
complications. Monitor INR diligently. Assess CBC for
anemia; urine/stool for occult blood. Be alert
to complaints of abdominal/back pain,
severe headache, confusion, seizures,
hemiparesis, aphasia (may be sign of
hemorrhage). Decrease in B/P, increase in
pulse rate may be sign of hemorrhage.
Question for increase in amount of
menstrual discharge. Assess peripheral pulses;
skin for ecchymoses, petechiae. Check for
excessive bleeding from minor cuts,
scratches. Assess gums for erythema, gingival
bleeding.

Patient/family teaching
 Take medication at same time each
day.
 Blood levels will be monitored
routinely.
 Do not take, discontinue any other
medication except on advice of
physician.
 Avoid alcohol, aspirin, drastic dietary
changes.
 Consult with physician before surgery,
dental work.
 Urine may become red orange.
 Falls, subtle injuries, esp. head or
abdominal trauma, can be life-
threatening.
 Report bleeding, bruising, red or
brown urine, black stools.
 Use electric razor, soft toothbrush to
prevent bleeding.
 Report coffee-ground vomitus, blood-
tinged mucus from cough.
 Do not use any OTC medication
without physician approval (may
interfere with platelet aggregation).
 Seek immediate medical attention for
stroke-like symptoms (confusion,
difficulty speaking, headache, one-
sided weakness); bloody stool or urine.
NAME OF DRUG MECHANISM OF INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION
GENERIC NAME:   treatment of severe Occasional (5%–3%):
Norepinephrine Stimulates beta1- hypotension Anxiety, bradycardia, Baseline assessment
adrenergic receptors, palpitations. Assess EKG, B/P continuously (be alert to
BRAND NAME: alpha-adrenergic Rare (2%–1%): precipitous B/P drop). Be alert to patient
Levophed receptors, increasing Nausea, anginal pain, complaint of headache.
contractility, heart rate shortness of breath, Intervention/evaluation
CLASSIFICATION: and producing fever. Monitor IV flow rate diligently. Assess for
Vasopressor vasoconstriction. extravasation characterized by blanching of
Increases systemic B/P, skin over vein, coolness (results from local
coronary blood flow. vasoconstriction); color, temperature of IV
site extremity (pallor, cyanosis, mottling).
Assess nail bed capillary refill. Monitor
I&O; measure output hourly, report urine
output less than 30 mL/hr. Once B/P
parameter has been reached, IV infusion
should not be started unless systolic B/P falls
below 90 mm Hg.