UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

MSI & MSII PATIENT ASSESSMENT TOOL .

Student:
Vanessa Munoz
Assignment Date:
Agency: LRMC

1 PATIENT INFORMATION
Patient Initials: G.D.

Age: 68

Admission Date: 2/22/16

Gender: Female

Marital Status: Married

Primary Medical Diagnosis Cardiac and respiratory

arrest

Primary Language: English

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Retired, Civil service

None

Number/ages children/siblings:
1 brother- 62
2 sons, one passed away, the other is 41
Served/Veteran:
If yes: Ever deployed? Yes or No
Living Arrangements:
House with husband

Code Status: Full code

Culture/ Ethnicity /Nationality: Non-Hispanic White

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date:
Procedure:
3/1-Dual chamber ICD
3/3- ANV ablation

Religion: Church of Christ

Type of Insurance: Cigna

1 CHIEF COMPLAINT:
My heart I guess

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient is a 68 year old female transferred from C3ICU on 2/27, originally came in to ER because of cardiac and
respiratory arrest. Was extubated on Friday and has been doing well since. Only problem today is that she had some chest
pain due to the chest compressions given by EMS. Her pain is at a 4 out of 10, which is considered a comfortable level
for her. She is going for an ICD placement this afternoon and also has an AVN ablation scheduled for Thursday.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

Father

59

Mother

73

Brother

62

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)
Heart
attack
Multiple
myeloma

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Age (in years)

10/2/2014
4/2015
1/8/2016
Unknown

Hypertension, hypercholesterolemia
Diabetes type 2
Arthritis
R. total knee replacement
COPD
Cardiac cath stent placement
CAD w/ occluded RCA Failed PCI in 1/2016
CHF
A fib

Alcoholism

1974
2000

Sister
relationship
relationship
relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years? Not within 10 years
Influenza (flu) (Date) Is within 1 years? N0, 10/3/14
Pneumococcal (pneumonia) (Date) Is within 5 years? Yes, 10/3/14
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Levaquin

Type of Reaction (describe explicitly)

Skin feels stingy, burns and itches

Medications

None
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)
A cardiac arrest is usually a sudden onset when a persons heart looses function. This can occur in a person who has
previously been diagnosed with a heart problem or with someone who has no cardiac history at all. Cardiac arrest usually
results from arrhythmias that cause the hearts electrical system to malfunction. (Huether, & McCance, 2008). A group that
is most at risk is older African American males. Other risk factors include having coronary artery disease, past heart
attacks, history of arrhythmias, personal or family history of sudden cardiac arrest, and drug and alcohol abuse (Who Is at
Risk for Sudden Cardiac Arrest?). A cardiac arrest is usually sudden so it is not usually diagnosed until after the patient
has been treated. Test that help diagnose a cardiac arrest include EKGs, echocardiography, cardiac MRI, cardiac
catheterization, and blood test. A cardiac arrest has to be treated immediately; the best choice would be a defibrillator
since a cardiac arrest is an electrical problem. The most common treatment if a person survives a cardiac arrest is
placement of an ICD.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name
Heparin

Concentration
25,000 Units/ 500mL

Dosage Amount
500mL
*wasnt sure how to fix this

Route
Frequency
IV
Continuous
Pharmaceutical class
Home
Hospital
Anticoagulant
Indication
DVT prophylaxis
Adverse/ Side effects
Bleeding
Heparin induced thrombocytopenia
anemia
Nursing considerations/ Patient Teaching
Assess for signs of bleeding, teach patient to report signs of abnormal bruising/bleeding
Monitor platelet count
Instruct patient not to take with NSAIDs
Avoid IM injections
Teach pt to avoid activities that can cause injury
Name
Sodium chloride- 0.9% Normal Saline
Route
IV
Pharmaceutical class
Mineral/ electrolyte replacement/supplements
Indication
Maintenance fluid
Adverse/ Side effects
Hypernatremia

or

Both

Concentration
1000mL

Dosage Amount
1000mL
Frequency
Continuous
Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Hypervolemia
IV irritation
Nursing considerations/ Patient Teaching
Assess fluid balance
Name
Concentration
lisinopril (Prinivil)
10mg/tab
Route
oral
Pharmaceutical class
Home
Antihypertensive
Indication
Hypertension
Side effects/Adverse
Dizziness, cough, diarrhea, impaired renal function, hyperkalemia, and angioedema
Nursing considerations/ Patient Teaching
monitor blood pressure and pulse before and during therapy
assess for signs of angioedema (facial swelling, dyspnea)
and monitor renal function with BUN and creatinine levels.

Name
Concentration
spitonolactone (Aldactone)
12.5mg/ 1 tab
Route
Oral
Pharmaceutical class
Home
Potassium sparing diuretic
Indication
Hypertension
Adverse/ Side effects
Dizziness
Headache
Hyperkalemia
Nursing considerations/ Patient Teaching
Monitor blood pressure and pulse before and during therapy
Teach patient about medication compliance
Avoid salt substitutes
Caution patient to avoid sudden movements and driving because of dizziness
Name
Concentration
valsartan (Diovan)
80mg/ 1 tab
Route
Oral
Pharmaceutical class
Home
Angiotensin 2 receptor antagonist
Indication
Hypertension
Adverse/ Side effects
Dizziness
Headache
Hyperkalemia
Hypotension
Angioedema
Nursing considerations/ Patient Teaching
Monitor blood pressure and pulse before and during therapy
Teach patient about medication compliance
Avoid salt substitutes
Caution patient to avoid sudden movements and driving because of dizziness
Assess for signs of angioedema (facial swelling, dyspnea)
Name
cefazolin (Ancef)
Route
IVPB
Pharmaceutical class
First generation cephalosporin
Indication
Preoperative prophylaxis
Adverse/ Side effects
Seizures
C. diff

Dosage Amount
1 tab
Frequency
bid
Hospital

or

Both

Dosage Amount
1 tab
Frequency
Daily
Hospital

or

Both

Dosage Amount
1 tab
Frequency
bid
Hospital

or

Both

Concentration
2,000mg/50mL

Dosage Amount
50mL
Frequency
Pre-op 100mL/hr for 30min
Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Rash
Pain at IM site
Phlebitis at IV site
Allergic reactions
Nursing considerations/ Patient Teaching
Asses for infection before and throughout
Obtain allergy history prior to administration
Observe for signs of anaphylaxis (rash, pruritus. Wheezing)
Monitor bowel function for signs of C. diff
Assess for rash
Name
aspirin
Route
Oral
Pharmaceutical class
Salicylates
Indication
MI prophylaxis
Side effects/
Bleeding
Dyspepsia
Epigastric distress
Tinnitus

Concentration
81 mg/1 tab

Dosage Amount
1 tab
Frequency
Daily
Home

Hospital

or

Both

Nursing considerations
Take with full glass of water
Report ringing in ears or abnormal bleeding
Name
arformoterol (Brovana)
Route
Nebulizer
Pharmaceutical class
Adrenergic
Indication
Maintenance to prevent COPD bronchospasm
Adverse/ Side effects
Headache
Weakness
Paradoxical bronchospasm
Tachycardia
Rash
Nursing considerations/ Patient Teaching
Instruct patient on proper technique
Dont double dose
Not for acute treatment

Concentration
15mcg/ 2mL

Name
albuterol
Pharmaceutical class
Adrenergic
Indication
Maintenance to prevent COPD bronchospasm
Adverse/ Side effects
Headache
Weakness
Hyperglycemia
Paradoxical bronchospasm
Tachycardia
Rash
Nursing considerations/ Patient Teaching
Instruct patient on proper technique
Dont double dose
Not for acute treatment

Concentration
2.5 mg/0.5mL

Name
insulin lispro (Humalog)
Route
SC
Pharmaceutical class
Pancreatic

Concentration
100 units/mL

Dosage Amount
2mL
Frequency
bid
Home

Hospital

or

Both

Dosage Amount
0.5mL
Home

Hospital

or

Both

Dosage Amount
Low corrective scale
Frequency
Low corrective scale
Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication
Diabetes
Adverse/ Side effects
Hypoglycemia
Nursing considerations/ Patient Teaching
Teach proper administration technique
Demonstrate technique for mixing insulin
Instruct patient of proper testing of blood glucose
Look for signs of hypoglycemia
Name
Concentration
furosemide (Lasix)
10mg/1mL
Route
IV push
Pharmaceutical class
Home
Loop diuretic
Indication
HTN
Adverse/ Side effects
Dehydration
Hypocalcaemia
Hypomagnesaemia
Hyponatremia
Dizziness
Nursing considerations/ Patient Teaching
Instruct pt to notify health care provider if wt gain occurs
Contact provider of rash, muscle weakness, cramps, or numbness occurs
Continue taking medication even if feeling better

Name
Concentration
famotidine (Pepcid)
20mg/1tab
Route
Oral
Pharmaceutical class
Home
Histamine h2 antagonist
Indication
Prevention of stress induced upper GI bleed in critically ill patients
Adverse/ Side effects
Confusion
Dizziness
Arrhythmias
Anemia
Nursing considerations/ Patient Teaching
Avoid alcohol, aspirin, NSAIDs
Increase fluid and fiber intake
Report onset of black tarry stools

Dosage Amount
40mg
Frequency
Q12h
Hospital

or

Both

Dosage Amount
1 tab
Frequency
bid
Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac 60
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Low sodium
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Pateint
Myplate recommendations
Breakfast: 2 eggs, grits, bacon, toast
Grains
6oz
6 oz
Veggies
0 cups
2 cups
Lunch: Ham and cheese sandwich
Fruit
0
2 cups
Dairy
0.5 cups
3 cups
Dinner: Usually goes out for dinner
Protein
4.5 oz
5 oz
Snacks: Graham crackers, bananas, yogurt
Sat. fat
13g
22 g max
Liquids (include alcohol): About 5 cans of Coke/day
Sodium
1938mg
2300mg max
Total cal
~2500
2000 max
The first thing I noticed that was wrong with this patients diet is
that she drinks about 5 cans of coke a day. She also says she eats
out every night, which can add a lot of calories since portion sizes
at restaurants are bigger than recommended. Recommendations I
would make is to make sure she knows proper portion sizes. If
she eats out for dinner every night she should ask for lighter
portions or save half of the meal for lunch or dinner the next day.
Id also recommend cutting out soda complete and to drink water
instead. Salt should be limited to 1500mg/day, meats should be
low in sodium and saturated fat. Id recommend eating vegetables
and fruit as a side or snacks throughout the day. Cheese should be
limited since its high in sodium. (Huether, & McCance, 2008).
(these are prompts designed to help guide your discussion)

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
My husband
How do you generally cope with stress? or What do you do when you are upset?
I like to do word searches

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
None

+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? _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?

University of South Florida College of Nursing Revision September 2014

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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:
The ego integrity vs despair happens in late adulthood. People in the ego integrity stage are happy with their lives
and are proud of their life accomplishments. Those in despair feel like they have not done enough with their life and wish they could
have done more and regret not accomplishing their goals earlier in life. (Varcarolis & Halter, 2010)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the ego integrity stage. Her age puts her in this stage. My patient has gone through a lot because of her health
but she doesnt show any signs of depression or despair. She has a loving family and a husband who stayed by her side throughout
her hospitalization.

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

The hospitalization could potentially put her in a state of depression, instead she is hopeful that the ICD and AVN ablation
will maker her life longer and decrease her hospital admissions.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My heart
What does your illness mean to you?
Well if you dont take care of your heart, it wont take care of you

+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________________________ If yes, are you in a monogamous relationship?
Yes_________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _Birth control when younger_________________________________
How long have you been with your current partner?_31 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 September 2014

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
_Its importent____________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
__yes_________________________________________________________________________________________________
______________________________________________________________________________________________________

+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? Cigarettes
How much?(specify daily amount)
1 day daily

Yes
No
For how many years? 47 years
(age 17

thru year 2013

If applicable, when did the

patient quit? 2013

Pack Years: 47
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit?

If yes, what did they use to try to quit? varenicline
(Chantix)

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No
5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF: 30
Bathing routine: daily
Other:

Be sure to answer the highlighted area

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
x/day
Routine dentist visits
not since she
got dentures
x/year
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? July 2015
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: o+
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 6
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes

Type: 2

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/24/16
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? March 2015
menstrual cycle
regular
irregular
menarche
age? 11
menopause
age? Stopped in 1998
Date of last Mammogram &Result: March
2015, normal
Date of DEXA Bone Density & Result:
December 2015, normal
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

Childhood Diseases
Measles
Mumps

University of South Florida College of Nursing Revision September 2014

10

Myocarditis
Arrhythmias
Last EKG screening, when? 2/24/16
Other:

Gout
Osteomyelitis
Arthritis
Other:

Polio
Scarlet Fever
Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

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

University of South Florida College of Nursing Revision September 2014

11

10 PHYSICAL EXAMINATION:
General Survey: Pt is a
Height 165.1cm
Weight 86.1
BMI 31.6
Pain: (include rating and
68 y/o female who is
location)
Pulse 78
Blood Pressure: (include location)
alert and oriented x3
Chest 4/10
160/70
Respirations 18
Temperature: (route
SpO2
Is the patient on Room Air or O2
99
taken?)37.3
O2 2L via 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
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
Central access device Type: Peripheral IV
Fluids infusing? no
yes - what? 0.9 NS

Location: Right forearm

loud

Date inserted: 2/22/16

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
Patient was answering questions appropriately so hearing was not
assessed Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Dentures
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL D
LUL D
RML D
LLL D
RLL D

Chest expansion

CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

12

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds pt has a
heart murmur
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Patient is in Normal Sinus

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:
3 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
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
Last BM: (date 2 / 29 / 16 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
GU
Urine output:
Clear
Cloudy
Color: Yellow
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output: 2000
without assistance

Musculoskeletal:
Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ___5____ RUE ____5___ LUE ___5____ RLE

or

mLs N/A

with assistance

& ___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 paresthesia
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 not
assessed
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride- pt
isnt walking yet
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:

2 Achilles:

Ankle clonus: positive negative Babinski: positive

negative

University of South Florida College of Nursing Revision September 2014

13

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):

Lab
WBC

Dates

Normal: 4.5-11.0
4.6

2/29

4.7
RBCs

3/1

Trend
Patients WBC stayed
normal throughout
admission

Patients RBCs were low

on admission; the
increased by a little but
are still low.

Normal: 3.8-5.1
3.56

2/29

3.62

3/1

HgB

Patients Hgb was low on

admission and did not
improve

Normal: 12.0-16.0
9.6

2/29

9.6

3/1

Hct

Patients Hct was low on

admission and did not
improve

Normal: 40.7-50.3
30.5

2/29

31.1

3/1

Plt
Normal: 150-450

Patients plt count stayed

normal throughout
admission

Analysis
Number of infection
fighting cells. High
WBC indicates the
presence of an infection
or inflammation. Low
WBC means patient is at
risk for infections
The main function of
RBCs is to transport
oxygen throughout the
body. The cause of this
patients low RBC can be
explained by her CHF.
CHF affects the kidneys
production of EPO
which affects RBC
production
Hgb is the protein that
carries oxygen. The
cause of this patient low
RBC can be explained by
her CHF. CHF affects the
kidneys production of
EPO which affects RBC
production
Hct is the percentage of
RBCs in whole blood.
The cause of this patients
low RBC can be
explained by her CHF.
CHF affects the kidneys
production of EPO
which affects RBC
production. Since RBCs
are low, Hct will also be
low
Platelets assist in blood
clotting. High levels
could indicate clotting

University of South Florida College of Nursing Revision September 2014

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224

2/29

243
BUN

3/1
Patients BUN stayed
normal throughout
admission

Normal: 6-20
13

2/29

13
Na

3/1

Normal 135-145
139

2/29

137

3/1

K
Normal 3.5-5
3.1

2/29

3.7

3/1

INR
Normal 2-3
1.0

3/1

Pt
Normal 11-14
10.8
Cr
Normal: 0.7-1.4

problem and low could

indicate a bleeding
problem.

3/1

BUN is checked for

kidney function, it is a
product of protein
breakdown in the
kidneys. High or low
BUN could indicated
kidney failure
Patients Na stayed normal Sodium plays a role in
throughout admission
maintaining blood
pressure. Water follows
sodium in the body. A
high sodium level could
increase blood volume
and therefore increase
blood pressure, it is also
indicative of
dehydration. Low
sodium levels could
mean theres too much
water, or not enough
sodium.
Patients K was low on
Potassium helps move
admission but was raised nutrients into cells and
to a normal value
takes waste out of cells.
It also plays a role in
nerve and muscle
function. The low value
is seen with patients who
have CHF
Patients INR is below
INR can be done as
normal range
preop procedure. It is a
ratio of the patients pt.
Low INR means its
taking longer to clot
which can make bleeding
a problem
Patients pt is below
Pt is the amount of time
normal range
it takes for plasma to
clot. It can be used to dx
bleeding and clots. Low
levels indicate its taking
the blood longer to clot.
Patients cr is below
Creatinine levels
normal range
determine how the
kidneys are functioning

University of South Florida College of Nursing Revision September 2014

15

0.5

2/29

0.5

3/1

Ca

Patients Ca is below
normal range, although it
is increasing

Normal: 9-11
7.3

2/29

8.6

3/1

Co2

Patients Co2 was high on

admission and has
remained high

Normal: 23-29
31

2/29

33
Cl

3/1
Patients Cl stayed normal
throughout admission

Nomral: 96-106
102

2/29

98
Troponins

3/1

0.5, 1.26, 0.48

The troponin level started

to increase but the third
one decreased again

Echocardiogram

No trend

LVEF 55%
Mild concentric LVH
Dilated LA
Mitral regurgitation
Aortic stenosis
EKG
Widespread ST
depression

2/24

No trend

in the body. It is a waste

product found in the
muscle. High creatinine
levels could indicate
renal problems. Low
levels could indicate
muscle dystrophy
Calcium helps support
skeletal structure and
function in the body. It
also has smaller roles in
cell signaling, blood
clotting, muscle
contraction, and nerve
function.
Co2 levels are taken as a
routine metabolic or
electrolyte panel. This
patient has COPD,
elevated Co2 levels are
expected with this
disease process.
Chloride maintains
normal fluid balance and
acid-base balance in the
body.

Troponins are ordered to

diagnose a heart attack.
An elevation in troponins
is an indication that there
has been some damage to
the heart
An echo allows
monitoring of the
function of the valves
and heart. Since she
patient was a cardiac
history, an echo is
expected. The LVEF
An EKG was done
because the patient had a
cardiac arrest. ST
depression is a sign of
myocardial ischemia or
coronary insufficiency

University of South Florida College of Nursing Revision September 2014

16

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,

multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
This patient is on a cardiac 60 diet in the hospital, at home she follows a low sodium diet. I would recommend
cutting out soda of her diet and drinking more water. The patients vitals were monitored hourly, her last set of
vitals were BP 160/70 P 78 SpO2 99% 2L via NC Temp 37.3 RR 18 Pain 4/10, chest from CPR. She has not
gotten out of bed, she uses a bed pan. She was extubated on Friday and was removed from the artic sun and bear
hugger. She has a scheduled dual chamber ICD on 3/1 and an ANV ablation on 3/3. The doctor recommended this
because it is not the first time this patient has been admitted because of cardiac and respiratory arrest, she has
been in 3 times since December; he said she most likely would not survive another event and this was the best
option for her. Patient will be discharged after the procedures if she tolerates them well.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Decreased cardiac output r/t altered contractility as evidenced by decreased ejection fraction
2. Risk for decreased cardiac tissue perfusion related to hypertension
3. Activity intolerance r/t prolonged bed rest as evidenced by dyspnea upon exertion
4. Risk for impaired skin integrity r/t surgical procedure and prolonged bed rest
5.

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 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t altered contractility as evidenced by decreased ejection fraction
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Display vital signs within
Auscultate apical pulse, assess
Tachycardia is usually present to
acceptable limits, dysrhythmias
heart rate, rhythm.
compensate for decreased
absent/controlled, and no
ventricular contractility. atrial
symptoms of failure (e.g.,
fibrillation is common
hemodynamic parameters within
dysrhythmias associated with HF
acceptable limits, urinary output
adequate) throughout shift.
Note heart sounds.
S1 and S2 may be weak because of
diminished pumping action. S3and
S4 sounds are commonly produced
as blood flows into noncompliant
chambers. Murmurs may reflect
valvular incompetence.

Client will state she wants to

participate in activities that lower
blood pressure / cardiac work by
time of discharge.

Evaluation of Goal on Day Care

is Provided
Patients vitals stayed within her
normal levels

Pt had a heart murmur

Patient had an adequate urine

output, 2000mL

Monitor urine output

Kidneys respond to reduced

cardiac output by retaining water
and sodium

Encourage rest

Physical rest should be maintained

during acute or refractory HF to
improve efficiency of cardiac
contraction and to decrease
myocardial oxygen demand/
consumption and workload.
Comparison of pressure gives a
more complete picture of the
involvement of vascular problems.

Patient remained resting in bed all

day, either watching tv, talking with
family or sleeping

Pulse on the carotid, jugular, radial

and femoral probably observed /
palpable . Pulse in the legs may be

All pulses were palpable

Monitor your blood pressure,

Measure in both arms / thighs for
initial evaluation
Note the presence, quality of
central and peripheral pulses

University of South Florida College of Nursing Revision September 2014

Blood pressure was within baseline

levels

18

decreased , reflecting the effect of

vasoconstriction ( increased SVR )
and venous congestion
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
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 decreased cardiac tissue perfusion related to hypertension
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Patient will demonstrate behaviors Teach patient relaxation techniques Anginal pain is often precipitated
to improve circulation (exercises
and how to use them to reduce
by emotional stress that can be
she can do in bed) by end of shift
stress.
relieved non-pharmacological
today
measures such as relaxation.

Display vital signs within

acceptable limits, dysrhythmias
absent/controlled, and no
symptoms of failure throughout
shift

Reposition the patient every 2

hours
Assess patient pain for intensity
using a pain rating scale, for
location and for precipitating
factors.

Evaluation of Goal on Day Care

is Provided
Patient rested throughout the day

To prevent bedsores

Patient was able to self reposition

To identify intensity, precipitating

factors and location to assist in
accurate diagnosis.

Pain was monitored and treated

throughout the shift

Administer or assist with self

reduces the amount of blood
administration of vasodilators, as
returning to the heart, decreasing
ordered.
preload which in turn decreases the
University of South Florida College of Nursing Revision September 2014

All ordered meds were given

19

workload of the heart.

Monitor vital signs, especially
pulse and blood pressure

Tachycardia and elevated blood

Vitals signs stayed within patients
pressure usually occur with angina baseline
and reflect compensatory
mechanisms secondary to
sympathetic nervous system
stimulation.
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
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

20

References

Ackley, B. J. & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). St Louis, MO: Elsevier.
Huether, S. E.; & McCance, K.L. (2008). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby.
Mahnke, D. (2014). Small Bowel Obstruction Information. Retrieved from http://www.mountsinai.org/patientcare/health-library/diseases-and-conditions/small-bowel-obstruction
Vera, M. (2013). 7 Inflammatory Bowel Disease (IBD) Nursing Care Plans. Retrieved February 15, 2016,
from http://nurseslabs.com/7-inflammatory-bowel-disease-nursing-care-plans/
Unbound Medicine, Inc. (2014). Nursing Central (1.22.) [Mobile application software].
Retrieved from < https://itunes.apple.com/us/app/nursingcentral/id300420397?mt=8>
varcarolis, E. M., & Halter, M. J. (2010). Foundations of psychiatric mental health nursing (7th ed.). St Louis,
MO: Elsevier.
WebMD. (2014, November 14). Bowel Obstruction. Retrieved from http://www.webmd.com/digestivedisorders/tc/bowel-obstruction-topic-overview?page=2

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