UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Shawn Hekkanen

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 10/1/2015

Agency: TGH - SBN

Patient Initials: AAA

Age: 74 years old

Admission Date: xx/xx/2015

Gender:

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Nonrheumatic Mitral Valve Insufficiency/ I34.0

Male

Primary Language: English

Level of Education: 2 Masters Degrees- History, English

Occupation (if retired, what from?): Retired Agent Federal Bureau of

Investigation
Number/ages children/siblings: 1 son (38 years old), 1 daughter (42
years old)
Served/Veteran: Veteran Army 2 tours Vietnam, honorable
discharge
Living Arrangements: lives with wife and rents properties in
Virginia, Florida, the country of Vietnam throughout the year

Culture/ Ethnicity /Nationality: Caucasian, born United States,

ancestors are from Britain
Religion: No affiliation

Other Medical Diagnoses: (new on this admission):

atrial fibrillation(I48.91), sleep apnea(G47.30,
Pulmonary HTN(I27.0), chronic bronchial
cough(R05), extended spectrum beta
lactamase(Z16.12)

Code Status: Full Code

Advanced Directives: Completed
If no, do they want to fill them out?
Surgery Date: 9/22/2015
Procedure: mitral valve repair, coronary artery
bypass graft harvested from left saphenous vein

Type of Insurance.: (retired) Federal Employee

Plan, Medicare

1 CHIEF COMPLAINT:
Patient checked into Tampa General Hospital after drastic increases in episodes of dyspnea, fatigue, and severe headaches.
Patient reports he was unable to catch his breath after grocery shopping. He has a history of care under a cardiologist in
Virginia for mitral valve insufficiency, pulmonary hypertension, and atrial fibrillation. I could not catch my breath. It hurt
and I panicked. It was scary. I ate right, exercised, and did a lot right. I could not catch my breath and I usually can after
resting a bit. My mitral valve was not supposed to go out so soon. I saw my cardiologist in Virginia just before coming to
Florida. Patient reported that this pain was a 10 and it was pressure.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient reports that he has been on a planned vacation in Florida from Virginia. He had been diagnosed with minor mitral
valve insufficiency many, many years prior, under the care of a cardiologist in Virginia. Patients other formal diagnoses
prior to this hospitalization include malignant hypertensive heart disease without congestive heart failure, paroxysmal
atrial fibrillation, and pulmonary hypertension arterial disease. In June 2015, an echocardiogram had results of pulse

University of South Florida College of Nursing Revision August 2013

pressure 60mmHg and pulmonary hypertension. Ejection fraction was within normal range. Patients Virginia
cardiologist had approved the patient for travel to Florida in August, under their agreed upon treatment plan, whereby the
patient would not have surgery until severe failure of the mitral valve. The onset of severe dyspnea lead to hospitalization.
Patient had intended to stay in Florida for two months before returning to Virginia. He is currently having pain from the
surgical incision that is over the length of the sternum. He reports a pain level of 7, and is aching, intermittent, and has
gradual onset. Relief occurs by PRN medication hydrocodone-acetaminophen. Movement may make the pain worse.
Patient reported thinking that he may have been able to successfully delay surgery until, I would be old enough not to go
through with it. Patient did not want to immediately have the heart surgery at TGH, hoping to return to Virginia. He
consented to two other procedures, a colonoscopy and esophagogastroduodenoscopy with closed biopsy, due to
constant heartburn, tarry stool, and having the feeling that food was stuck behind his sternum. Since the patient
had adapted a disciplined lifestyle to have a heart healthy diet and daily light exercise, he reports that he was hoping to
medicate through the mitral valve regurgitation crisis without surgery. Patient now has been diagnosed with an extended
spectrum beta lactamase infection and has contact precautions. Breathing treatments are daily for lung congestion and
productive cough. He is not on an oral antibiotic. The plan is to eventually discharge to a Florida rehab facility. The
patient reports weakness in legs and arms. He becomes easily tired and easily dizzy. During the evaluation he thought his
son was 28 years old instead of 38 years old. However, all other recall appeared to be accurate and immediate. Patients
wife appears to be integral to any treatment plan for both support and correct application.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date

Operation or Illness

1998
2001
2008
8/31/2015
8/31/2015
9/22/2015
9/24/2015

Esophagogastroduodenoscopy with closed biopsy

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

living

Cancer

78

Bleeds Easily

unknown

Asthma

91

Arthritis

Mother

Anemia

89

Environmental
Allergies

Father

Cause
of
Death
(if
applicable
)
unknown

Alcoholism

Coronary artery bypass graft (CABG) with harvest from Left saphenous vein, repair of mitral valve
Noted infection of Extended Spectrum Beta Lactamase (ESBL) contact precautions
Age (in years)

2
FAMILY
MEDICAL
HISTORY

Left inguinal hernia repair

Right inguinal hernia repair
Lithotripsy for kidney stone
colonoscopy

Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

Patient reports that the only known existing family health issues were hypertension in mother and environmental allergies
Sister has no known health issues. Children have no known health issues. Grandchildren have no known health issues.
Nobody in my family has mental health issues or substance abuse issues. Never.

University of South Florida College of Nursing Revision August 2013

 1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations: (Note- patient is 78 years old)
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date) 11/2014 (intention to get flue shot this year
Pneumococcal (pneumonia) (Date): unknown
Have you had any other vaccines given for international travel or
occupational purposes? Please List: encephalitis, typhoid, Hep A & B
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

YES

NO

Type of Reaction (describe explicitly)

No known Drug
Allergies or adverse
drug reactions

No known drug allergies

Some environmental
grasses especially in
Virginia (unknown
specific grass,
occurs in spring and
fall)

Rhinitis, itchy eyes treated with OTC Benadryl

Medications

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)
The most common cause of mitral valve insufficiency is leaflets of the valve are remodeled due to increased proteinases
and myofibroblast infiltration (Huether & McCance, 2012). Blood leaks back into the atrium during ventricular
contraction. Prevalence of disorder is 2.4% of the United States adult population, and there is a link to being a dominant
allele of inheritance. During the fifth to sixth week of gestation, the mitral valve formation can be disrupted by
environmental factors. Often, mitral valve insufficiency does not have any overt symptoms. The murmur is discovered
during routine examination by auscultation. Discovery may also be confirmed by echocardiography. If symptomatic,
patients can experience dysrhythmias, tachycardia, dizziness, syncope, fatigue, lethargy, weakness, dyspnea, chest
tightness, hyperventilation, anxiety, depression, and atypical chest pain. Left sided heart failure can cause pulmonary
hypertension (Huether & McCance, 2012). Severity and emergence of specific symptoms are difficult to match to the
level of prolapse. Most patients do not have restricted activities or medications. However, beta-blockers may be
prescribed, especially for dizziness and palpitations. Clinical findings and echocardiograph may indicate that a person
with mitral valve insufficiency would also be at risk for endocarditis, stroke, and sudden death. A bioprothetic or
mechanical heart valve may replace the faulty mitral valve. Bioprosthetics are from a cow or a pig, and usually last about
10-20 years (Osborn, Wraa, Watson, & Holleran, 2014). Long-term anticoagulant prescriptions are not as common. Clot risks

University of South Florida College of Nursing Revision August 2013

are higher for mechanical valve replacement and lodge right on the valve. The patients blood levels for coagulants have
to be carefully monitored, and anticoagulant therapy will be prescribed.

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

docusate sodium(COLACE)

Route

by mouth

Concentration

Dosage Amount 100mg

Frequency

Pharmaceutical class: stool softener

Home

Hospital

BID (twice daily)

or

Both

Indication Constipation prevention to avoid straining, especially after MI, heart surgery, or rectal surgery
Side effects/Nursing considerations: throat irritation, abdominal cramps, diarrhea, and rashes. Assess for abdominal distention, auscultate bowel sounds, and
record bowel patterns of elimination. Assess color, odor, consistency, and amount of stool
Name
Route

guaifenesin (MUCINEX)

Concentration

Dosage Amount 600mg

by mouth

Frequency

Pharmaceutical class: expectorant; allergy/cold/cough

Home

Hospital

BID every 12hr PRN for congestion and cough

or

Both

Indication: For productive cough related to upper respiratory infection. Reduces viscosity of bronchial secretions by increasing amount of fluid in respiratory
tract.
Side effects/Nursing considerations: dizziness, headache, nausea, diarrhea, rash, hives, vomiting, light-headedness. Assess lung sounds and frequency/character
of cough and bronchial secretions. Maintain 1500-2000mL water intake to potentiate effect on secretion viscosity and limit light-headedness.
Name

heparin (porcine)

Concentration

Dosage Amount

Route subcutaneous injection abdomen

Frequency

Pharmaceutical class: antithrombotics

Home

Hospital

5000units

BID
or

Both

Indication: Prophylaxis or treatment of thromboembolism related disorders throughout circulatory system. Anticoagulant.
Side effects/Nursing considerations: Bleeding, thrombocytopenia, anemia, alopecia with long-term use, and osteoporosis with long-term use. Assess for signs of
bleeding and hemorrhage, such as nosebleeds, bruising, tarry stools, fall in hematocrit or fall in BP. Observe injection sites for hematoma, bruising, and
inflammation. Monitor platelet count.
Name hydrochlorothiazide (HYDRODIURIL)
Route

Concentration

Dosage Amount: 25mg

by mouth

Frequency

Pharmaceutical class: thiazide diuretics

Home

Hospital

daily
or

Both

Indication: Management of mild to moderate hypertension. Treatment associated with heart failure, renal dysfunction, cirrhosis, and glucocorticoid therapy.
Side effects/Nursing considerations : hypotension, cramping, Stevens Johnson syndrome, rash, hyperglycemia, hypokalemia, hyperuricemia, and hypovolemia.
Monitor BP, heart rate, intake/output, daily weight, and edema especially in lower extremities, low sodium, low magnesium, and high calcium. Monitor dizziness
and orthostatic hypertension. Fall risk.
Name HYDROcodone-acetaminophen (NORCO)

Concentration

Dosage Amount: 5-235mg per tablet

Route

Frequency PRN every 6 hours

Pharmaceutical class: opioid agonist w/ non-opioid analgesic

Home
Hospital
or
Both
combination
Indication: Management of Mild Pain(1-3) to Moderate Pain(4-6) that is daily, around-the-clock, and long-term.
Side effects/Nursing considerations: Do not exceed 4g of acetaminophen combined from all sources within 24 hours. Confusion, dizziness, sedation, euphoria,
urinary retention, constipation, respiratory depression, vision changes, headache, unusual dreams.
Name insulin aspart (NOVOLOG)

Concentration

Dosage Amount

Route subcutaneous injection

sliding scale

Frequency: Three times daily with food and at bedtime

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: Blood sugar <150 No insulin, 150-199 4 units, 200-249 8 units, 300-349 12 units, 350-399 15 units, 400 or above STAT lab blood glucose and call
provider. Control of hyperglycemia in patients with diabetes or induced hyperglycemia through medications or surgical procedure. Tight glucose control speeds
wound healing.
Side effects/Nursing considerations: Food must be on the floor in order to give insulin or risk hypoglycemic reaction. Hypoglycemia, allergy/anaphylaxis,
lipodystrophy if injection sites are not rotated, itching, redness, swelling
Name ipratropium-albuterol (DUO-NEB)
Route

Concentration (0.5mg-3mg(2.5mg base)/3mL

aerosol

Frequency

Pharmaceutical class: anticholinergic and adrenergic mixture

Home

Hospital

Dosage Amount

3mL

every 6 hours while awake by respiratory

or

Both

University of South Florida College of Nursing Revision August 2013

Indication: Management of bronchitis and respiratory secretions. Reversal of bronchoconstriction. Preventing airway obstruction.
Side effects/Nursing considerations: hypotension, rash, blurred vision, sore throat and irritation/dryness, headache, dizziness, nervousness, hypokalemia,
paradoxical bronchospasm, hyperglycemia. Assess vital signs before administration. Color, Odor, consistency and amount of secretion produced
Name irbesartan (AVAPRO)
Route

Concentration

Dosage Amount 300mg

by mouth

Frequency

Pharmaceutical class Angiotensin II receptor antagonist

Home

Hospital

nightly
or

Both

Indication: Management of hypertension alone or together with other agents. Treatment of diabetic neuropathy.
Side effects/Nursing considerations: Hyperkalemia, dizziness, angioedema, dizziness, hypotension, fatigue, rash, orthostatic hypertension. Assess BP lying,
sitting, and standing. Monitor especially potassium increase and fluid output.
Name magnesium hydroxide (MILK OF MAGNESIA)

Concentration 400mg/5mL

Route by mouth

Frequency

Pharmaceutical class: salines

Home

Hospital

Dosage Amount 30mL

daily PRN
or

Both

Indication: if no quality bowel movement occurs within 48 hours, administer. Bowel evacuant.
Side effects/Nursing considerations: diarrhea, flushing, sweating, sodium loss. Assess for heartburn and indigestion and gastric pain.
Name Magnesium sulfate in dextrose infusion 1 g

Concentration

Dosage Amount

Route intravenous

1g

Frequency one dose only

Pharmaceutical class minerals electrolytes

Home

Hospital

or

Both

Indication If hypomagnesium from most recent lab level below 1.5mg/dL for Mg electrolyte replacement. Treatment of HTN. Prevention of seizures associated
with eclampsia during pregnancy. May aid in bronchodilation.
Side effects/Nursing considerations: drowsiness, respiratory depression, bradycardia, hypotension, muscle weakness, flushing, sweating, hypothermia. Monitor
vital signs and ECG. Monitor cognitive status and intake/output of fluids.
Name meTOPROLOL (LOPRESSOR)

Concentration

Dosage Amount 12.5mg

Route by mouth

Frequency BID

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: Management of hypertension, angina pectoris, prevention of MI and decreased mortality after MI. Management of heart failure.
Side effects/Nursing considerations: Fatigue, weakness, hypotension, pulmonary edema, blurred vision, stuffy nose, hyperglycemia/hypoglycemia, joint pain,
and dizziness. Erectile dysfunction, urinary frequency. Monitor BP, ECG, pulse, intake/output of fluids, weight gain, JVD, masks hypoglycemia.
Name Nifedipine (ADALAT CC)

Concentration

Dosage Amount

Route by mouth

30mg

Frequency daily

Pharmaceutical class: calcium channel blockers

Home

Hospital

or

Both

Indication: Management of HTN, angina, HF, cardiomyopathy.

Side effects/Nursing considerations Do not crush or chew. Arrhythmias, HF, peripheral edema, bradycardia, hypotension, dizziness, orthostatic hypotension,
shortness of breath, nocturia, erectile dysfunction, flushing, paresthesia, breast development in males. Monitor BP, pulse, and intake/output(I/O) ratios before
administration, Monitor ECG with long-term therapy. Assess for rash affiliated with Stevens-Johnson syndrome.
Name Ondansetron HCl (ZOFRAN)
Route

Concentration 4mg/2mL

Intravenous

Dosage Amount 2mL

Frequency PRN every 4 hours

Pharmaceutical class antiemetic

Home

Hospital

or

Both

Indication Prevention of nausea and vomiting , especially after surgery and chemotherapy.
Side effects/Nursing considerations: Headache, dizziness, weakness, constipation, creation of torsade de pointes arrhythmia, abdominal pain, dry mouth,
increased liver enzymes. Single dose IV over 2-5 minutes as undiluted solution
Name pantoprazole (PROTINIX)

Concentration

Dosage Amount 40mg

Route by mouth

Frequency every morning before breakfast

Pharmaceutical class: proton pump inhibitor

Home

Hospital

or

Both

Indication: Erosive esophagitis associated with GERD.

Side effects/Nursing considerations: Headache, hyperglycemia, pseudomembranous colitis, abdominal pain, diarrhea, flatulence, hypomagnesemia, and
diarrhea. Assess patient for abdominal pain, epigastric pain, blood in stool, emesis, and aspirate from stomach.

University of South Florida College of Nursing Revision August 2013

Name Potassium chloride

Concentration

Dosage Amount

Route by mouth

20mEq-40mEq

Frequency PRN daily

Pharmaceutical class: mineral and electrolyte supplements

Home

Hospital

or

Both

Indication: Treatment and prevention of potassium depletion and arrhythmias associated with hypokalemia. [Order: potassium 3.2-3.5mEq(dose 40mEq); 3.63.9 (dose 20mEq).]
Side effects/Nursing considerations: Confusion, restlessness, weakness, abdominal pain, paresthesia, and arrhythmias. Assess for symptoms of arrythmia caused
by hyperkalemia, as well as other associated symptoms, such as muscle weakness, fatigue, peaked T waves, depressed ST segments, prolonged QT, wide QRS,
and loss of P wave.
Name senna-docusate (SENOKOT-S) 8.6-50mg tablet
Route

Concentration

Dosage Amount 1 tablet

by mouth

Frequency BID

Pharmaceutical class: stimulant laxative, stool softener

Home

Hospital

or

Both

Indication: Treatment of constipation associated with dry, hard stool, and decreased peristalsis.
Side effects/Nursing considerations: Abdominal cramps, nausea, vomiting, electrolyte imbalance, and dehydration. Assess for presence of bowel sounds, and
usual pattern of bowel function, and color/consistency amount of stool.
Name

tamsulosin (FLOMAX)

Concentration

Dosage Amount

Route by mouth

Frequency

Pharmaceutical class: peripherally acting antiadrenergic

Home

Hospital

0.4mg

daily
or

Both

Indication: Management of outflow obstruction in male patients with prostatic hyperplasia.

Side effects/Nursing considerations: Dizziness, headache, runny nose, and orthostatic hypotension. Assess for feeling of incomplete bladder emptying and return
to normal rate of emptying, fall risk, input/output ratio, and rectal exam before and throughout therapy.
Name warfarin (COUMADIN)

Concentration

Dosage Amount 5mg

Route by mouth

Frequency

Pharmaceutical class

Home

Hospital

daily
or

Both

Indication
Side effects/Nursing considerations: Administer at same time daily after checking INR labs for therapeutic level(usually 2-3).
Name Aspirin

Concentration

Dosage Amount: 81mg

Route by mouth

Frequency

Pharmaceutical class: salicylates

Home

Hospital

daily
or

Both

Indication: Management for inflammation, prophylaxis of MI and TIA, control of mild to moderate pain, and osteoarthritis/rheumatoid arthritis.
Anticoagulant to prevent thrombosis or prevent worsening thrombosis.
Side effects/Nursing considerations: Tinnitus, abdominal pain, ulcers, bleeding, anemia, hives, rash, heart burn, anorexia, laryngeal edema, hepatotoxicity.
Persons who have asthma, allergies, and nasal polyps are at increased risk for hypersensitivity reactions. Monitor liver enzymes, do not give to young children
due to Reyes Syndrome.
Name atorvastatin (Lipitor)
Route by mouth

Concentration

Dosage Amount: 80mg

Frequency: nightly

Pharmaceutical class: hmg Coensyme A reductase inhibitor

Home
Hospital
or
Both
(therapeutic class: lipid-lowering agent)
Indication: Adjunctive management of hypercholesterolemia. Prevention of coronary heart disease for patient with high LDL and low HDL.
Side effects/Nursing considerations: Flatulence, erectile dysfunction, peripheral edema, abdominal cramps, constipation, rhabdomyolysis, joint pain,
angioneurotic edema. Before administration, obtain a diet history, especially about fat consumption. Evaluate blood levels of cholesterol and triglycerides after
2-4 weeks of therapy and throughout. Monitor muscle tenderness and CPK levels for excessive breakdown. Monitor liver enzymes. May cause premature
gaining by weakening telomeres.

5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Special Diet Low salt, low fat,
Analysis of home diet (Compare to My Plate and
low sugar
Diet pt follows at home? Low saturated fat, low cholesterol Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: eggs, oatmeal, 2 cups coffee, Orange Juice
This patient is a 78 year old male, 61, 210lbs. He gets

University of South Florida College of Nursing Revision August 2013

Lunch: Patient reports never eats lunch, drinks water/juice

Dinner: restaurant dining 4-5 times per week: must serve
fish (e.g. Bonefish Grill, Roys Hawaiian Restaurant)
2 pieces Grilled Salmon, wild rice, asparagus, 3-4 glasses
red wine
Snacks: generally none
Liquids (include alcohol): wine 500mL with dinner at
restaurant 4x per week (250-375mL at home 3x per week);
water 960mL daily, orange juice 720mL daily

44% of his recommended grains intake. His 24 hour recall

indicates he is not eating appropriate My Plate portions().
The recall indicates he currently eats 44% of recommended
grain intake, with 4.0oz equivalents of the recommended
9.0 oz. equivalents. Vegetable intake is 29% of daily
recommendation, with 1.0 cup equivalents of the
recommended 3.5 cup eq. Fruit intake is 200% of the
recommended intake, with 4.0 cups equivalents of the
recommended 2.0 cups equivalents. However, the intake is
of poor quality as store bought juice. Unprocessed fruit is
preferable. The patient denies dairy intake and opts to take
a calcium citrate pill with vitamin D. The recommended
dairy value is 3.0 cup equivalents. Protein intake is 46% of
the recommended daily intake, with 3.0oz equivalents of
the recommended 6.5oz equivalents. Specific
recommendations made for this patient by My Plate
include, aiming for 8.0 teaspoons of oils a day, limiting
extra fats and sugars to 410 calories, and varying vegetable
intake. If the patient remains on warfarin with the same
diet, then vitamin K intake will affect the INR level. The
dosage of warfarin would be adjusted accordingly to keep
INR at a therapeutic level to rehabilitation. The patient is
taking in 1823.61 calories, which is 70 % of the
recommended 2,623 recommended calories for a
moderately active 78 year old male.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

University of South Florida College of Nursing Revision August 2013

 1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife. Patients wife is in good health and is over 10 years younger.
How do you generally cope with stress? or What do you do when you are upset?
I walk with my wife around the neighborhood. Also goes to city parks to walk. Go out to dinner frequently. Talk to
family on the phone. Patient also goes to the gym 3-4 times per week and walks on the treadmill. Patient does not do any
resistance training.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reports feelings of being overwhelmed by recovery. He has always been healthy and was living with mitral valve
regurgitation for 10 years.

+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. Never unsafe.
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? Yes, very. My wife is excellent support. I think I have a great relationship with
my kids.

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:
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient is 78 years old, thus is in stage 8, ego integrity versus despair. This patient has a strong relationship with his
wife. He often looks to her to confirm his thought process. He also reports having a positive relationship with his 38 year
old son and 42 year old daughter. He was very open to discuss his job at the FBI as a desk agent, and showed genuine
concern for completing the PAT evaluation when it had to be broken into several sessions throughout the day. This reveals

University of South Florida College of Nursing Revision August 2013

generativity. The patient has tried to live extremely healthy and extremely busy, during his retirement. He does not own
any homes, only rents. He most often travels between Florida, Vietnam, and Virginia. Virginia is what he calls home.
However, he travels all over the world. He feels that both of his children are secure and reports that feels that he did the
best I could. He appears to like to be defined by his time in the FBI, his wife, his children, and grandchildren. He leads a
very busy and active social life, going out to dinner at least four times a week with friends, in whatever region he is
renting.

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

This is a horrendous bump in the road. This patient is struggling with why this happened to me. He thinks he made
every effort to be healthy and prevent heart surgery. He reports being worried that surgery will have slowed him down too
much to continue to be a fun partner for his wife. He does not appear concerned with himself, even with the why question.
He appears to be mostly concerned about affecting his family negatively, especially his wife.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I dont know. I have been trying to figure it out ever since I got here. Why me? I was healthy out of the [military] service.
My wife and I live healthy.
What does your illness mean to you?
A horrendous bump in the road and a tremendous challenge.

+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? ___women______________________________________________
Are you aware of ever having a sexually transmitted infection? __No_____________________________________
Have you or a partner ever had an abnormal pap smear?____N/A____________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ____No____________________________
Are you currently sexually active? ___[General refusal to answer personal sexual questions at beginning of sexuality
assessment. This question was not asked to maintain trust with patient and respect of his personal boundaries and privacy.]
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? __N/A- wife is not of child-bearing age________________________________
How long have you been with your current partner?____44 years- exclusive relationship_________________________
Have any medical or surgical conditions changed your ability to have sexual activity? None by known history.
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 August 2013

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

What importance does religion or spirituality have in your life?
My family, you could say, is my spirituality. I am not spiritual or religious.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
I dont have religious beliefs.
______________________________________________________________________________________________

+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?(specify daily amount)
N/A
N/A

Yes
No
For how many years? 0 years
(age

thru

If applicable, when did the

patient quit? N/A

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? No tobacco use in household.

Has the patient ever tried to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
475mL - 500mL at restaurant 4 nights
Wine (usually red wine) nightly
per week
250mL - 375mL at home 3 nights per
Wine (usually red wine) nightly
week
If applicable, when did the patient quit?

For how many years?

(age

60 years old

thru current )

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
N/A
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
Patient reports no known exposure to hazards from occupational history or environmental history, including time
in army service and Federal Bureau of Investigation. Patient had two tours in Vietnam. Patient was an agent until retired
around 55 years old. The FBI has a mandatory retirement age.

University of South Florida College of Nursing Revision August 2013

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 10 REVIEW OF SYSTEMS
General Constitution

Gastrointestinal

Recent weight loss or gain

*less appetite, some loss due to hospital
food

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen None
SPF: none
*Does not expose self to sun
Bathing routine: AM Daily, bed bath
Other: incision midline sternal vertical
incision present for 8 days
Wound Right elbow incision present for 7
days

Immunologic

Nausea, vomiting, or diarrhea

Chills with severe shaking

Constipation
GERD
Indigestion
Hemorrhoids
Yellow jaundice
Pancreatitis
Colitis

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor

Irritable Bowel
Cholecystitis
Gastritis / Ulcers
Blood in the stool
Hepatitis

Diverticulitis

Life threatening allergic reaction

Appendicitis

Enlarged lymph nodes

Abdominal Abscess
Last colonoscopy? 8/31/2015
Other:

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
Routine dentist visits
Vision screening 1x/year
Other:

Genitourinary
nocturia (while in hospital)
dysuria
hematuria
polyuria
kidney stones (2008 lithotripsy)
Normal frequency of urination:
4x/day
Bladder or kidney infections

Other:

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

Metabolic/Endocrine
2x/day
2x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other: Patient is not diagnosed with
diabetes but has insulin ordered for tight
glucose control to aid in healing and
prevent medication side effects.

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies: some grasses
last CXR? 9/30/2015
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD

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?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam? annual
Date of last prostate exam?
BPH: not diagnosed but taking a med
for it
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

University of South Florida College of Nursing Revision August 2013

11

CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? current
admission
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis- osteoarthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No other problems that I know of. My wife and I keep up to date on all our medical stuff.

Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision August 2013

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10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey:

Height: 61
Pulse: 105
Respirations: 25

Weight: 210lbs BMI: 27.7 Pain: (include rating & location)

7 middle chest surgical
Blood
incision over sternum, onset
Pressure: 136/62
Temperature: (route taken?)
(include location)
gradual, aching, intermittent
96.8F (by mouth)
SpO2: 95%
Is the patient on Room Air or O2: 4L per minute O2
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 (feet are cool)
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: 20G

Location: Right cephalic vein lateral side of arm
Date inserted: 9/30/2015
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
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 / 3mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 20
inches & left ear- 20
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions(not
assessed)
Dentition: No dental problems by report. Attends dentist twice yearly
Comments:

University of South Florida College of Nursing Revision August 2013

13

Pulmonary/Thorax:
CL

CR
Ab

CL

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
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

CR

Diminished, Crackles

Ab

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th ICS mid-clavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
An ECG was unfortunately not gathered for analysis. The patient has a history of Atrial fibrillation and an example is
pictured below. This is where the atrium is quivering and failing to contract blood into the ventricle in regular volume.The
p-wave is irregular because depolarization of atrium is irregular. There is blood stasis in the atria and possibility of a
thrombus. An anticoagulant helps prevent this. Prior history to this patients current hospitalization was paroxysmal atrial
fibrillation, so it was episodic instead of continuous.

Calf pain bilaterally negative

Pulses bilaterally equal Apical pulse: 105bpm (+2 strength) Carotid: 105bpm (+1 )
Brachial: not assessed
Femoral: not assessed
Popliteal: not assessed
DP: 105 (+1)
PT: not assessed
No temporal or carotid bruits
Edema: 0
Location of edema:
N/A
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

Radial: (+1)

GI/GU:
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
Urine output:
Clear
Cloudy
Color: dark yellow
Previous 24 hour output: 1400mL
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date
10 / 01 / 2015, 0545) Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

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 (weakness in all extremities)
Strength bilaterally equal at ___3____ RUE ___3____ LUE ___3____ RLE & ___3____ 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 w/ symmetric stride (not assessedpatient requires assistance to stand by two staff)
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: not assessed
Achilles: not assessed

Biceps: not assessed

Brachioradial: not assessed
Ankle clonus: positive negative Babinski: positive negative

Patellar: not assessed

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
Potassium
Normal: 3.5-5.3mmol/L
10/1: 4.4
9/28: 3.6

CO2
Normal: 22-29mEq/L
10/1: 29
9/28: 31

Glucose
Normal: 70-110mg/dL
10/1: 94

WBC
Nrml:4.6-10.2
10/1: 3.87
9/27: 3.34

Dates

Trend
Supplementation
keeping potassium
above 4. Should not
change with careful
observation of holding
diuretic as related to
most recent blood value.
Lowering with
treatment by
respiratory therapist.

Analysis
Has stayed in reference
range but safer after
heart surgery to be
above 4.0.

Patient is having trouble

taking deep breaths due
to lung secretions,
ventilation is stymied.
Needs to continue to use
incentive spirometer
and cough up secretions.
More difficult with fluid
restriction 1500mL/day.
Glucose has always been Hyperglycemia impedes
within limits. Insulin
healing after surgery,
was ordered as
but patient is not
precaution due to age
diagnosed diabetic. He
and heart surgery.
is eating 50% of hospital
meals, because he does
not like hospital food.
WBC is rising. Patient
Due to patient having
Crea
has infection
an infection of extended
spectrum beta
lactamase, I would

expect the WBC count

to be higher. Poor
circulation may inhibit
distribution of WBC.
Patient is struggling
with eating enough food
to maintain proper diet
and is losing weight.
May need B-12, folic
acid, iron
supplementation if does
not eat enough.

RBC
Normal: 4.04-5.48
10/1: 3.61
9/28: 3.3

RBC is rising to normal

values

Hgb
Normal: 12.2-16.2g/dL
10/1: 9.4
9/27: 8.8

Hgb is rising to normal

values

Hemoglobin may
require iron
supplementation but at
risk of constipation.
Needs to eat more. Also

Platelets
Normal: 142-424
10/1: 291
always normal

Within normal range.

Active anticoagulant
therapy appears to not
be overdone. May need
increase since patient
having difficulty with
ambulation.

Protime
Normal: 11-13.5sec
10/1: 17.9
9/29: 15.7

Clotting time is
increasing.

Anticoagulant therapy
is effective by this bench
marker.

INR
Normal: 0.8-1.1
Therapeutic: 2-3
10/1: 1.6
9/28: 1.5

INR is above normal

but not within normal
therapeutic value.

Patient is being slowly

acclimated to the
therapy due to risk from
heart surgery of
bleeding. Doctors may
not want to use normal
therapeutic value.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)

Diet: MCLS, 2000cal, 1500mL fluid intake, no added salt (Na 4g)
Accucheks AC & HS (limit potential for high or low glucose interfering with healing. Heart medications can
cause hypoglycemia or hyperglycemia.
Patient has physical therapy once per day. Lift team put patient in chair for exercises yesterday. Today, patient
was placed in chair by nurse and this writer.
Daily breathing treatments and incentive spirometer are used to cough up respiratory secretions. No antibiotic for
extended spectrum beta lactamase.
Patient getting daily bed bath.
Vital signs taken hourly.
Social worker looking for rehab placement.
Monitoring by telemetry, tachycardia, no audible murmur detected. Deep Q wave signals prior MI. Sinus Rhythm

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Ineffective breathing pattern r/t presence of tracheobronchial secretions.
2. Decreased cardiac output r/t impaired cardiac function, increased afterload, and increased preload.
3. Excess fluid volume r/t decreased urine output.
4. Imbalanced nutrition: less than body requirements r/t inability to ingest food because of psychological factors.
5. Risk for injury: Risk factors of muscle weakness.

 15 CARE PLAN
Nursing Diagnosis: Ineffective breathing pattern r/t presence of tracheobronchial secretions.
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Teach patient to effectively use
Role model how to perform the
The incentive spirometer helps
Patient was actively using incentive
incentive spirometer and improve
proper rate of inspiration from the
prevent pneumonia and atelectasis spirometer and needed to be
depth of breathing by the end of
incentive spirometer. Repeat
(Osborn et al., 2014). The incentive reminded several times how to
shift.
demonstration and encouragement spirometer teaches the most
properly perform the slow, deep,
as needed. Breath with the patient
effective way to expand the lungs
steady breath. Patient effectively
while working on the incentive
to maximum inspiration is with a
learned how to use incentive
spirometer to control proper rate of slow, deep breath.
spirometer by repeated
inspiration.
demonstration back to nurse.
Initial incentive spirometer volume Patient will be encouraged to use
The incentive spirometer personal
Patient may have gotten volume of
of 800 at beginning of shift will be the incentive spirometer three
measures needs to be continuously 1100 by end of shift, by patients
1000 by end of shift.
times per hour to promote lung
improved upon to effectively
self-report. Patient used the
expansion.
promote lung health (Osborn et al., incentive spirometer 2-3 times
2014).
every hour.
Patient will report decreased
Ensure that client in dyspneic state The nurses presence, reassurance, All medications given on time. O2
anxiety from dyspnea, rated at a
has received any ordered
and consistent interaction will
on 4L. The patient frequently had
6, at beginning of shift, and will
medications, oxygen, and any other build trust. This can help control
to be reminded to use his heart
be rated a 2 or 3 at end of shift. treatment needed.
the clients breathing by controlling pillow when coughing. Sometimes
(1-10 scale)
anxiety (Ackley & Ladwig, 2007). this writer would hold pillow to
patients chest while coughing due
to patients arm weakness. The
patient reported a decreased
anxiety to 3, at end of shift.
Patient Goals/Outcomes

Patient will work towards more

independence of movement by
utilizing staff, and he will eat lunch
in the chair by the end of the shift.

Teach patient mindfulness related

distressing techniques in order to
help decrease anxiety and increase
deep, slow breathing.

Two staff will move the patient

every hour in bed to promote
movement of secretions. Patient
will isotonically flex feet and move
ankles to prepare for transfer to
chair. Patient will be encouraged to
spend at least 15 minutes in the
chair and converse with staff and
wife. Patients pain will be
managed with medications to
promote engagement in
conversation, eating, and other
activities while in chair.
Reveal to patient the methods of
using the five senses to absorb the
stimuli that surround constantly but
are not often noticed. Patient will
identify two stimuli from each of
his five senses that are helpful to
relax, and that he may be able to
utilize in the hospital.

Movement out of bed will increase

psychological independence
through accomplishment and
encourage movement of secretions
out of the lungs (Ackley & Ladwig,
2007). Small, frequent feedings
avoid compromising ventilator
effort. An upright position
facilitates lung expansion.

Patient was assisted with two staff

into a chair. Patient wore non-slip
socks. He reported a sense of
accomplishment. He ate in the
chair. The day before, the lift team
had to move him to chair. He
stayed in the chair for 45 minutes
before transfer back into bed with
two staff assist. Part of lunch was
eaten in chair.

Mindfulness slows the thinking

rate down, and allows the patient to
focus on the here and now. This
technique can prevent racing
thoughts and encourages deep,
slow breathing (Ackley & Ladwig,
2007).

Patient was able to talk through a

mindfulness-related exercise that
helped him remain calm, and
breathe more deeply and slowly.
Patient reported two coping
mechanisms for each of his five
senses-1) taste: gum, sugarless
candy; 2) smell: wifes perfume
sprayed on her picture or a piece of
paper; 3) touch: lucky rabbits foot
keychain feels like petting his dog,
holding wifes hand; 4) hear: wife
will bring in cd player with
headphones, talk to his grown kids
on telephone; 5) see: pictures of his
family, picture of dog. Patient
reported that he would attempt to
avoid smoke and areas with
excessive air pollution, such as a
NASCAR track or hockey rink.

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: Patient is having symptoms of pulmonary edema and may need fluid restriction in long term. MCLS diet.
PT/ OT: Refer to rehab in Florida or Virginia. Patient is having daily physical therapy in chair in hospital room.
Pastoral Care
Durable Medical Needs
F/U appts: Have Virginia cardiologist coordinate records and possibly a referral to another cardiologist in Florida.
Med Instruction/Prescription: Teach patient and wife how to properly administer medications, manage side effects, and understand when to return
to the hospital.
are any of the patients medications available at a discount pharmacy? Yes X No
Rehab/ HH: A rehab is being searched for patient in Florida most likely.
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t impaired cardiac function, increased afterload, and increased preload.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Patient will have limited fluid
All liquids will be counted,
Clear liquids include coffee, tea,
Patients fluid intake was
intake to 1,500mL. Increased
including Jell-O, etc. Nurse will
water, clear juices, Jell-O, hard
approximately 900mL by end of
afterload and preload is related to
faithfully chart intake of all liquids. candy (Osborn et al., 2014).
shift. Patient was to be catheterized
oliguria.
Patient will be bladder scanned for Patients with difficulty urinating
after end of student nurses shift as
urine to ensure that patient to use a are bladder scanned to determine
bladder scan revealed 110mL.
straight catheter, as patient only
the need for a catheter, based upon Patient was printed information,
sometimes urinates on command.
the knowledge that the bladder
including side effects, on all
Patient is taking a medication for
holds 400-600mL (Osborn et al.,
medications that he was not
Benign Prostatic
2014). Patient should be educated
familiar and given an opportunity
Hyperplasia/Hypertrophy and he
on their medications to more
to ask questions.
did not know it. All blood pressure efficiently gain control of their
medications will be cross-checked discharge planning (Ackley &
with lab values and appropriate
Ladwig, 2007).
medications will be given on time.
Patient will demonstrate
Patient will demonstrate adequate
Patients knowledge of symptoms
Patient was able to demonstrate
knowledge of the primary and
knowledge cardiac output as
will encourage preventative care
with wife basic knowledge of his
2ndary characteristics of decreased evidenced by knowledge of
and lessen potential for crisis care. usual primary and secondary
cardiac output. Patient will
symptoms, such as fatigue,
Patients that are more
symptoms of decreased cardiac
demonstrate knowledge of when to dyspnea, edema, orthopnea,
knowledgeable about all aspects of output. Nurse aided patient in
call provider based upon
paroxysmal nocturnal dyspnea, and their care are more likely to be
understanding what symptomatic
symptoms.
increased central venous pressure.
compliant (Huether & McCance,
information should definitely be
Secondary characteristics include
2012).
forwarded to provider or require
weight gain, hepatomegaly, jugular
emergency care. Patient
venous distension, crackles,
demonstrated knowledge of the 20
coughing, clammy skin, oliguria
minute ischemic rule that results in
and skin color changes.
cellular apoptosis.
Patient will be active today. He will Patient will be assisted by two staff Exercise is begun gradually in
Patient spent about 45 minutes in
move to chair from bed. He will
members into the chair from the
heart surgery patients. If pain or
the chair, conversed and ate part of
perform physical therapy and eat
bed. Patient will be encouraged to
dyspnea is felt, then the patient
lunch, before returning to the bed.
lunch in chair.
spend at least 30 minutes in the
stops, relaxes, releasing the O2
chair, doing normal activities and
demand on the myocardium
conversing. Pain will be managed
(Osborn et al., 2014).
with medications in order to

promote a high level of activity and

engagement in physical therapy.
Refer to a dietician to increase food Assess the difficulty with eating
intake to use dietary protein to
MCLS diet from the hospital.
promote healing.
Assess whether cultural factors are
causing difficulty with hospital
menu. Patient has a wife from
Vietnam and they eat a lot of fish.

The patient will learn prioritized

information of each prescribed
medication and how all his
prescriptions work together.

Patient needs to increase protein

intake to promote healing after
surgery (Huether & McCance,
2012). A hospital should encourage
choice as much as possible in all
aspects of hospitalization.
Encouraging choice is easiest with
the food menu(Osborn et al.,
2014).
Patients that understand the
indications and side effects of their
medications are more compliant
with treatment (Huether &
McCance, 2012).

Patient reported that he is only

eating about 50% of every meal
due to not liking the hospital food.
He reported that this is under
doctor order to avoid outside food.
A dietary consult was requested, as
he is receiving items on his food
tray that are not his preference. He
is a choosy eater.
The patient was given printouts and
discussed his personal past history
of side effects and adverse
reactions to medications. He
appeared to be well-educated on his
care, but patients wife had more
knowledge than patient.

The client will understand the

indications, side effects, and when
to hold each medication due to
vital signs, as well as when to call
the provider. Beta blockers are
never held because of the risk of
rebound effects and MI. However,
in hypotensive states, the beta
blocker dosage may be reduced
under the care of the provider.
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
X Dietary Consult: MCLS diet.
XPT/ OT: Patient is receiving physical therapy in the hospital. He will be transferred to a rehab.
Pastoral Care
X Durable Medical Needs: Patient will be on heart medications for the rest of his life. He will need to reduce his alcohol intake from 3-4 glasses of
red wine per dinner to one or none.
X F/U appts The patient will require a follow-up appointment near or inside the rehab where he will be transferred.
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes X No
X Rehab/ HH
Palliative Care

References
Ackley, B. J. & Ladwig, G. B. (2007). Nursing diagnosis handbook: An evidence-based
guide to planning care (8th ed.). St. Louis: Mosby/Elsevier.
Choose MyPlate. (n.d.). Retrieved October 5, 2015, from http://www.choosemyplate.gov/
Huether, S. E., & McCance, K. L. (2012). Understanding Pathophysiology (5th ed.). St. Louis, MO: Elsevier
Mosby.
Osborn, K., Wraa, C., Watson, A., Holleran, R. (Eds.). (2014). Medical-surgical nursing: Preparation for
practice (2nd ed.). Upper Saddle River, New Jersey: Pearson.