UNIVERSITY OF SOUTH FLORIDA COLLEGE OF NURSING

Student: Noor Tamari

PATIENT ASSESSMENT TOOL .

Patient Initials: Gender: Male Primary Language: English Level of Education: Some college Occupation (if retired, what from?): Retired- Previously employed as a supervisor of oil plant. Number/ages children/siblings: 2 brothers (70 and 74), 1 son (42), 1 daughter (39) D.S. Age: 76 Marital Status: Married

Assignment Date: 02/01/2013 Agency: Sr. Josephs Hospital

Admission Date: 01/17/2013 Primary Medical Diagnosis with ICD-10 code: I21.19 Other Medical Diagnoses: CAD, DM- type 2, BPH

Code Status: FULL Living Arrangements: Lives in a mobile home with wife. It is a one story home but there are a few stairs in the entrance. Culture/ Ethnicity /Nationality: American Religion: Christianity Type of Insurance: Medicare Advanced Directives: NONE Surgery Date: 1/18/13 Procedure: CABG

2 CC: I had pain and pressure in my chest.

3 HPI: This patient is a 76-year-old Caucasian male who was admitted on 01/172013 with complaints of chest pain. The patient stated it began 2 weeks ago during his trip to Hawaii. He stated the pain began in his bowel and spread upward to his chest. He described it as a dull pain that would come and go. He stated, the pain would get worse when I had gas but better when I burped. There was evidence of an acute myocardial infarction. The patient was sent for an emergent left heart catheterization which showed severe multivessel coronary artery disease. He has a history of hypertension, benign prostatic hyperplasia and diabetes type 2. The patient was taking Flomax 0.4 mg daily and Cozaar 100mg daily at home. The patient received a coronary artery bypass on 01/18/13. Denies any present chest pain or shortness of breath. The patient is currently on a cardiac diet, is an Acue check ACHS, and is scheduled to receive physical therapy once a day, 5 days a week.

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 2 PMH/PSH Hospitalizations for any medical illness or operation

Date 1970 1970 1987 1980 Operation or Illness Diabetes type 2 HTN BPH Appendicitis Management/Treatment Insulin Cozaar 100mg daily Flomax 0.4mg daily Appendectomy

(angina, MI, DVT etc.) Heart Trouble

Kidney Problems

Environmental Allergies

Mental Problems Health

Stomach Ulcers

Bleeds Easily

Hypertension

2 FMH

Age (in years)

Alcoholism

Glaucoma

Diabetes

Arthritis

Seizures

Anemia

Asthma

Cancer

Father Mother Brother Sister

relationship relationship relationship

8 3 9 1

Cause of Death (if applicable) Prostate Cancer CHF

Comments:

1 IMMUNIZATION HISTORY YES Routine childhood vaccinations Routine adult vaccinations for military or federal service Adult Diphtheria (1998) Adult Tetanus (1998) Influenza (flu) (January 2010) Pneumococcal (pneumonia) (1998) Have you had any other vaccines given for international travel or occupational purposes? Please List 1 Allergies or Adverse Reactions
Medications NKDA NAME of Causative Agent Type of Reaction (describe explicitly)

NO

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Tumor

Stroke

Gout

Other (food, tape, dye, etc.)

NKFA NKOA

3 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment) An ST segment elevation myocardial infarction (STEMI) is related to myocardial injury associated with ST segment elevation on the ECG. This means that myocardial tissue is undergoing severe cellular damage. In most cases this is a result of complete coronary artery blockage from thrombus occlusion over an underlying plaque lesion. Presenting signs vary from person to person. Usually symptoms include chest pain, diaphoresis, shortness of breath, and generalized weakness. The blood pressure may be low due to decreased cardiac output or it may be high due to catecholamine release, fear, and anxiety. Laboratory tests include myoglobin, cardiac enzymes, troponin, and possibly a C-reactive protein level. A rise in cardiac blood markers occurs when the myocardial cells become damaged from a lack of blood supply that occurs with myocardial injury and death. On admission to the emergency departments, patients are made NPO, put on bed rest, given supplemental oxygen, and undergo continuous cardiac and oxygen saturation monitoring. The mnemonic MONA, which stands for morphine, oxygen, nitroglycerin aspirin, describes the protocol for patients with suspected myocardial infarctions. Since STEMI is due to formation of a blood clot in a coronary artery, the mainstay of treatment is thrombolytic therapy to dissolve the clot. Primary angioplasty is an option for STEMI, if the facility is locally available. Some patients who present with only mild symptoms of angina or who are even asymptomatic may benefit from CABG. However, there must be sustained evidence that CABG will prolong survival. Age, diabetes, CAD, family history and smoking are all risk factors for the developments of acute coronary syndrome. If blood flow is not reestablished in 20 minutes, cell death occurs. If the occlusion is treated early, a patient presenting with STEMI may suffer only subendocardial cell damage without subsequent Q waves.

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010).Medical surgical nursing:, Preparation for practice (1st ed.). Upper Saddle River, NJ: Prentice Hall

5 MEDICATIONS: (Include both prescription and OTC)

Name tamsulosin(Flomax) Route PO Pharmaceutical class antiadrenergic Reason for taking Management of BPH Home Concentration 0.4mg = 1 cap Frequency 1x Daily Hospital or Both X Dosage Amount 1 cap

University of South Florida College of Nursing Revision January 2010

S/S dizziness, headache, orthostatic hypotension Name asprin ec (Ecotrin) Route PO Pharmaceutical class salicylates Reason for taking Prophylaxis S/S dyspepsia, epigastric distress, nausea, vomiting Name ascorbic acid (Vitamin C) Route PO Pharmaceutical class Reason for taking necessary for wound healing and immunity S/S heart burn, diarrhea, dizziness Name atorvastatin (Lipitor) Route PO Pharmaceutical class hmg coa reductase inhibitors Reason for taking Cholesterol management S/S abdominal cramps, constipation, diarrhea, flatus, heart burn Name pantoprazole (Protonix) Route PO Pharmaceutical class proton pump inhibitor Reason for taking decrease acid secretion and ulcer prevention S/S headache, diarrhea, hyperglycemia, bone fracture Name docusate sodium (Colace) Route PO Pharmaceutical class stool softener Reason for taking prevention of constipation S/S mild cramps, diarrhea Name metoprolol (Lopressor) Route PO Pharmaceutical class beta blocker Reason for taking decreased mortality in patient with recent MI S/S fatigue, Bradycardia, hypotension, pulmonary edema, weakness, anxiety Name ASPART insulin (NovoLOG) Route Subcute Inj Pharmaceutical class panreatics Reason for taking control of hyperglycemia S/S hypoglycemia, lipodystrophy, pruitis, erythema, swelling Home Concentration Frequency 3x Daily ac Hospital X or Both Dosage Amount BG minus 100, divided by 10 equals number of units to administer Home Concentration 12.5 mg = 0.5 tab Frequency q12 hr Hospital X or Both Dosage Amount 0.5 tab Home Concentration 100 mg= 1 cap Frequency 2 x Daily Hospital X or Both Dosage Amount 1 cap Home Concentration 40mg= 1 tab Frequency 1 x Daily Hospital X or Both Dosage Amount 1 tab Home Concentration 80mg=1 tab Frequency 1x Daily Hospital X or Both Dosage Amount 1 tab Home Concentration 500mg= 1tab Frequency 2x Daily Hospital X or Both Dosage Amount 2 tabs Home Concentration 81mg=1 tab Dosage Amount 1 tab

Frequency 1 x Daily with meals Hospital X or Both

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 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Cardiac Diet Diet pt follows at home? Regular Diet Breakfast: 2 eggs fried with nonstick spray, 1 Italian sausage also fried with nonstick spray, one slice of white toast that is toasted, 250 ml of regular orange juice Lunch: 1 cold cut turkey sandwich with 2 pieces of turkey, 2 slices of white toast and one spoon of mayonnaise. For a drink, he has one can or 355 ml of regular coke. Patient stated he receives three servings of food every day. His daily calories intake allowance is 2000 calories. He eats around 1436 calories. I would suggest to the patient to add a couple of snacks to his diet to increase intake, especially Analysis of home diet (Compare to food pyramid and Consider co-morbidities and cultural considerations):

dairy products since his intake for that is little to none. The target is 3 cups of dairy daily. An example of such foods would be a yogurt cup with fruit on the bottom or a glass of milk. Instead of friend chicken, salmon would a better alternative as it has less saturated fat and contains Vitamin D. He has a sodium intake of 2905 mg. I would suggest decreasing sodium intake to fewer than 2000 mg a day by increasing intake of fruits and vegetables. He needs 2 cups of vegetables each day and he only had 1. He needs 2 cups of fruit each day and he also only had 1. I would suggest adding a vegetable side such as broccoli to his lunch meal and fruits like strawberries to her snack routine. I would also recommend decreasing his protein intake as the daily allowance is 5 ounces and he had 9 ounces. I would also suggest an increase in B vitamin intake; evidence has shown that an increase in folic acid, vitamin B6, and vitamin B12 can help improve the clinical outcome of cardiac patients.
Dinner: One piece of fried chicken cooked with 2 spoons of butter, which he said is usually the thigh piece that is around 4 oz., with bread crumbs. On the side he has 3 ounces of mashed potatoes with margarine without gravy. For drink, he has 250 ml of water.

Snacks:

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 2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife is the one who helps me How do you generally cope with stress? or What do you do when you are upset? I usually dont stress out.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) Patient denied having any recent difficulties. 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? 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? If yes, have you sought help for this? No Are you currently in a safe relationship? Yes

5 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

Give the textbook definition of both parts of Ericksons developmental stage for your patients age group:

Integrity vs. Despair: Late Adulthood. Older adults review their lives, reflecting on what they have done and accomplished. If the retrospective evaluations are positive a sense of integrity is felt. That is, they can say to themselves My life was worth living. In contrast, older adults become despairing if, when they look backward, their evaluations are predominately negative. Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010).Medical surgical nursing:, Preparation for practice (1st ed.). Upper Saddle River, NJ: Prentice Hall
Describe the characteristics that the patient exhibits that led you to your determination:

I believe my patient is exhibiting characteristics of Eriksons integrity stage of psychosocial development. Patient stated he has a good family support system and enjoys spending time with his wife and two kids. He stated, I try not to stress and be positive. He is proud of his accomplishments and does not have many regrets.

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

My patient was admitted with a STEMI. This disease has impacted my patient in a way that allowed him to reflect back on his life. He denied feelings of depression and overall has a pleasant and positive mood. He stated that he enjoys spending time with his family, especially with his son and daughter. Once discharged, he wants to make some lifestyle changes so that he may continue to have that strong bond with his family and spend more time with his children. Cultural Assessment:

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What do you think is the causes of your illness? Eating the wrong stuff

What does your illness mean to you? That I need to make some changes

University of South Florida College of Nursing Revision January 2010

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

What importance does religion or spirituality have in your life? Its a major part of my life. I go to church every Sunday.

Do your religious beliefs influence your current condition? Makes me more at ease.

+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? How much? Marlboro Cigarettes 2 packs a day Yes No For how many years?
(age 21 thru 26 )

For cigarette use, what is the number of pack years? 5 years

If applicable, when did the patient quit? Age 26

Does anyone in the patients household smoke tobacco? If so, what, and how much? No 2. Does the patient drink alcohol or has he/she ever drank alcohol? X Yes What? Beer How much? 2-3 cans a week No For how many years?
(age 21 thru 26 )

If applicable, when did the patient quit? Age 26 3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No X If so, what? How much? For how many years?
(age thru )

Is the patient currently using these drugs? Yes

No X

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks Yes. Patient stated there is pollution at the oil plant he worked at. However, he also stated they had good air filters for protection.

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 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain patient lost 50 lbs last year)

Gastrointestinal
Nausea, vomiting, or diarrhea Constipation GERD Indigestion Hemorrhoids Yellow jaundice Pancreatitis Colitis Diverticulitis Appendicitis Abdominal Abscess Last colonoscopy? January 2012 Other: Irritable Bowel Cholecystitis Gastritis / Ulcers Blood in the stool Hepatitis

Immunologic
Chills with severe shaking Night sweats Fever HIV or AIDS Lupus Rheumatoid Arthritis Sarcoidosis Tumor Life threatening allergic reaction Enlarged lymph nodes Other:

Integumentary
Changes in appearance of skin Problems with nails Dandruff Psoriasis Hives or rashes Skin infections Use of sunscreen sometimes SPF: 15 Bathing routine: once daily Other:

HEENT
Difficulty seeing Cataracts or Glaucoma Difficulty hearing (hearing aids) Ear infections Sinus pain or infections Nose bleeds Post-nasal drip Oral/pharyngeal infection Dental problems Routine brushing of teeth 2 x/day Routine dentist visits 2 x/year Vision screening Other:

Hematologic/Oncologic
Anemia Bleeds easily Bruises easily Cancer Blood Transfusions Blood type if known: Other:

Genitourinary
nocturia dysuria hematuria polyuria kidney stones Normal frequency of urination: 5 Bladder or kidney infections

x/day

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? (1/22/2013)- protocol after chest tube removal- no evidence of postprocedure complications Other:

Central Nervous System

WOMEN ONLY Infection of the female genitalia Monthly self breast exam Frequency of pap/pelvic exam Date of last gyn exam? menstrual cycle regular irregular menarche age? menopause
age?

CVA Dizziness Severe Headaches Migraines Seizures Ticks or Tremors Encephalitis Meningitis Other:

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

Date of last Mammogram &Result: Date of DEXA Bone Density & Result: MEN ONLY Infection of male genitalia/prostate? Frequency of prostate exam? Every year Date of last prostate exam? Last year BPH Urinary Retention

Mental Illness
Depression Schizophrenia Anxiety Bipolar Other:

Musculoskeletal
Injuries or Fractures Weakness Pain

Childhood Diseases
Measles Mumps

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Myocarditis Arrhythmias Last EKG screening, when? (1/21/2013) Normal Sinus rhythm Other:

Gout Osteomyelitis Arthritis Other:

Polio Scarlet Fever Chicken Pox Other:

REVIEW OF SYSTEMS NARRATIVE General Health

Denies any previous fatigue, weakness, fever, chills, and sweats or night sweats. Patient stated he lost 50 lbs last year through diet and exercise. Patient bathes every day. Patient states he sometimes wears sunscreen outside spf 15.

Integumentary
Patient denies any changes in appearance of skin or any history of skin disease, pigment changes, mole changes, rashes, dry skin, psoriasis, dandruff. Patient denies changes in nail shape, color or brittleness. Denies any recent hair loss or change in textures. Patient brushes teeth twice daily and visits the dentist twice yearly. Patient stated he does have trouble hearing. Stated he has been wearing them for about 10 years. Patient stated wearing hearing aids helps with hearing, while background noise makes hearing more difficult.

Cardiovascular
Patient denies history of precordial pain, cyanosis, orthopenia, and paroxysmal nocturnal dyspnea. Patient has a history of hypertension. Onset was age 32. Duration is intermittent. Patient states, sometimes it goes up from time to time. Patient states he sometimes get a pulse feeling in my ear. It goes away on its own though. He states exercise helps relieve his hypertension. Patient takes Cozaar 100mg PO once daily for his hypertension. Denies discoloration of the hands or feet, varicose veins, intermittent claudication, or thrombophlebitis. Denies experiencing coldness, numbness, and tingling in feet or hands. Last EKG done on the 1/21/2013and the results were normal sinus rhythm.

GI
Denies dysphagia, heartburn, abdominal pain, pyrosis, vomiting blood, flatulence, diarrhea, black stools, rectal bleeding, or rectal conditions. Denies history of hemorrhoids, jaundice, colitis, cholecytitis, and hepatitis. Last colonoscopy performed on January 2012 and was negative for colon cancer.

GU
Patient states he normally urinates 5 times a day. Urine is generally light yellow in color. Patient also stated he has a prostate exam yearly. He stated he has a history of BPH. Onset was age 50. Stated he does have urinary hesitancy sometimes. Patient stated he takes Flomax 0.4 mg PO once a day for management.

General Constitution
Pts perception of health: Until I was admitted to the hospital, I thought my health was good. This just means I need to make changes and be more healthy.

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

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10

Do you prefer women, men or both genders? Women 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? I use protection How long have you been with your current partner? 10 years Have any medical or surgical conditions changed your ability to have sexual activity? Yes Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?No

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:
Orientation and level of Consciousness: Alert and oriented x3 General Survey: Patient is a Height:59 Weight: 92.955 kg BMI:30.3 Pain: (include rating & location) 0/10 well-developed 76 year old Pulse:75 bpm Blood male with no physical signs of Pressure: 113/66 (left arm) distress baseline: 139/66 (include location) Temperature: (route taken?) Respirations: 18 98.8 F (oral) SpO2 95% Is the patient on Room Air or O2: room air 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 apathetic bizarre agitated anxious tearful 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 talkative withdrawn quiet boisterous aggressive hostile flat loud

Peripheral IV site Type: 20 gage 1/20/2013 no redness, edema, or discharge Fluids infusing? no yes - what? Peripheral IV site Type: no redness, edema, or discharge Fluids infusing? no yes - what? Central access device Type: Fluids infusing? no yes - what?

Location:

right forearm

Date inserted:

Location: Location:

Date inserted: Date inserted:

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 Functional vision: right eye - 20 left eye - 20 without corrective right eye left eye with corrective lenses
lenses

Functional vision both eyes together: with corrective lenses or NA 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: right ear- less than 50% 24 inches & left ear- greater than
50% 24 inches

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12

Weber test, heard equally both ears resources) Nose without lesions or discharge Dentition: Patient wears dentures Comments:

Rinne test, air

time(s) longer than bone (not performed due to lack of

Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions

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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 Tactile fremitus bilaterally equal without overt vibration CR - Crackles Sputum production: thick thin Amount: scant small moderate large RH Rhonchi Color: white pale yellow yellow dark yellow green gray light tan brown red
D Diminished S Stridor Ab - Absent

Cardiovascular: No lifts, heaves, or thrills PMI felt at: 5th ICS ML Heart sounds: S1 S2 x Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD Rhythm (for patients with ECG tracing tape 6 second strip below and analyze) Assessed 1/22/2013- Normal Sinus Rhythm

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: 2 DP: PT:3 No temporal or carotid bruits Edema: [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 Liver span 8 cm 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: 1970 mLs N/A Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or X with assistance CVA punch without rebound tenderness Last BM: (date 1 / 22 / 2013 ) Formed X Semi-formed Unformed Soft Hard Liquid Watery Color: Light brown X Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Hemoccult positive / negative

Genitalia: Clean, moist, without discharge, lesions or odor Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus Strength bilaterally equal at _5______ in UE & __5_____ in LE
[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: +2
positive negative

Biceps: +2 X

Brachioradial:

+2

Patellar: +2

Achilles:

+2

Ankle clonus: positive negative x Babinski:

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): Labs (1/22/2013) RBC: 2.63 LOW(normal between 4.2-4.5) can be due to anemia and vitamin deficiency HGB: 8.3 LOW( normal between 14-18)anemia can be related to blood loss from to CABG. HCT 24.5 LOW(normal between 40-54)decreased level due to anemia PLT 104 LOW (normal between 150-450) certain medications can decrease platelet count LYMPH 16.4 LOW (normal 20-45) low lymph can be due to response to a virus or infection or medications Egfr >60 NORMAL Calcium 7.9 LOW(normal between 8.5-10.5) Hypocalcaemia due to inadequate vitamin D and calcium intake. BUN/Creatinine: 19 NORMAL(normal between 10-20) Chest X-ray (1/22/2013)- Removal of bilateral chest tubes. No pneumothorax

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: Physical Therapy 4 times a week Incentive Spirometer 10 times q 1h TCDB q2h Fall risk assessment q12h Vitals q4h Acue check ACHS

 8 Nursing Diagnoses (actual and potential - listed in order of priority)

1.Altered Nutrition; more than body requirement related to excess fat and sodium intake AEB BMI 30.3

2.Risk for decreased cardiac output related to decreased contractility and increased afterload secondary to myocardial infarction and hypertension

3.Risk for Fall related to unfamiliarity of environment, medication intake, and decreased mobility

 15 for Care Plan

Nursing Diagnosis: Altered Nutrition: More than body requirements related to excess fat and sodium intake AEB BMI 30.3 Patient Goals/Outcomes Nursing Interventions to Rationale for Interventions Evaluation of Interventions Achieve Goal Provide References on Day care is Provided
The client will design dietary At 10:00, assisted client to modifications to meet individual determine their body mass index. long-term goal of weight control by end of my shift. A normal BMI is 20 to 25; 26 to 29 is overweight; and a BMI of greater than 30 is obese. The calculated BMI for the client was 30. 3 which is considered obese. At 10:20, the client stated he would, make some changes like decreased his salt intake and exercise more to be healthier and loose more weight.

At 10:10, recommended the client use the interactive Food Guide Pyramid site at www.MyPyramid.gov to determine the number of calories to eat and gain more information on how to eat healthier. At 10:15, recommended to the client to continue to lose weight slowly, no more than 1 to 2 lbs. per week based on healthy eating pattern.

A systematic review found that safe choices for weight loss included low-calorie diets such as the DASH diet or a Weight Watchers type of diet. Slower weight loss is generally more likely to be lasting weight loss. It Is important that increased activity is included to help burn more calories.

Nursing Diagnosis: 3.Risk for fall related to unfamiliarity of environment, medication intake and decreased mobility Patient Goals/Outcomes
Patient will have no fall on my shift.

Nursing Interventions to Achieve Goal

At 09:00, positioned bed in low position. At 09:10, placed patients tray, phone, water mug, and call light within reach. Routinely assisted the client to the bathroom, ensuring to keep the path clear.

Rationale for Interventions Provide References

To ensure bed is closest to the ground and prevent a fall. To ensure clients belongings within reach. Clutter in the clients path is a risk factor for a fall.

Evaluation of Interventions on Day care is Provided

Patient did not have any falls during my shift.

 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 -Yes 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 Yes Rehab/ HH Yes
Patient is being discharged to home care. His wife will be at home to provide care and assistance when needed. He is scheduled for cardiac rehabilitation 2wice a week. This is to insure the patient will be able to return to his normal daily activities. I recommended to the client to weigh himself frequently and to include exercise in his weight loss plan. I also stressed the importance of following a cardiac diet. Before discharge the patient will be provided a list of scheduled medications which would include their indications, side effects, and when to call the prescriber. Both discharge medications, Flomax and Cozaar, are available at a discount pharmacy, such as Wal-Mart, Walgreens and CVS, for little to no cost to the client. The importance of follow-up care by the physician will be reinforced to observe patients progress.