UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Kristina Nealy

Assignment Date: 10/13/2015
PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency: Sarasota Memorial Hospital
Patient Initials: M.S. Age: 50 Admission Date: 10/12/2015
Gender: Male Marital Status: Married Primary Medical Diagnosis with ICD-10 code:
I21.19 ST Elevation Myocardial Infarction
Primary Language: English
Level of Education: Some college Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Pepsi Cola
Number/ages children/siblings: No children. 2 brothers, 1 sister

Served/Veteran: Yes/Army Code Status: Full Code

Living Arrangements: Lives with wife Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 10/12/15
Procedure: Cardiac Catheterization w/ stent
placement
Culture/ Ethnicity /Nationality: Caucasian
Religion: Catholic Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT: The doctor said I had a massive heart attack but I dont believe it. The patient
was admitted for an acute ST elevation myocardial infarction.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
This is a 50 year old male without any previous cardiac history. He is a heavy smoker and has not had any type of
physician follow up since he moved from Boston about two years ago. Three days prior to his hospitalization, he was
having intermittent substernal chest pain, nausea, and fatigue which he initially thought was a stomach infection. His pain
worsened to a 7/10 so he was brought into the emergency room. An EKG was performed which showed inferior wall ST
segment myocardial infarction, the DASH protocol was engaged and he was taken directly to the cath lab. His presenting
troponin was 30.67. He received Brilinta, aspirin, and nitrates prior to going to the cath lab. A stent was placed and he is
currently on 8 Courtyard for observation and post-operative care.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date Operation or Illness
1981 Appendicitis resulting in an appendectomy
2011 Pulmonary embolus: Pt took Warfarin for 2 years
Unknown Hyperlipidemia: Has not taken statin therapy for > 2 years
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY

Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
Cause

Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
Gout
MEDICA of

Mental
Heart
L Death

(angina,
HISTORY (if
applicable)
Colon
Father 70
Cancer (70)
Mother 75
Colon
Brother 44
Cancer (44)
Brother 39
Sister Colon
52
Cancer (52)
Comments: Include date of onset: Pt did not know much about his father or paternal and maternal grandparents. His
brother was diagnosed with colon cancer at 39, his sister never admitted she had colon cancer (but the family was told she
did) and passed on 3/31/2014.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) Unknown
Adult Tetanus (Date) November 2014
Influenza (flu) (Date) 2-3 weeks ago
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Rash, anaphylaxis
Benadryl Itchiness
Ibuprofen Itchiness
Medications

Other (food, tape,

latex, dye, etc.)

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 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)
Myocardial infarctions are classified as acute coronary syndrome. An acute inferior wall ST segment
myocardial infarction (STEMI) often indicates occlusion of the right coronary artery (RCA) and injury to the
muscle of the heart or the myocardium (Osborn, Wraa, Watson, Holleran, (2014)). Injury to the myocardial
tissue results when there is not enough oxygen is getting to the tissues, often due to a blockage of plaque
buildup in the artery that is stopping blood flow. Myocardial injury leads to cellular damage and if blood flow is
not reinstated within 20 minutes cell death occurs (Osborn et al., 2014). A STEMI is dangerous and requires
immediate medical attention. With any myocardial infarction, the patient may be asymptomatic (women more
often than men) or they may present with symptoms that arent typical so it is very important that patients are
aware of this and know what symptoms to look for. Often, men have chest pain, fatigue, nausea, vomiting,
dyspnea, anxiety and feeling of impending doom. Women have intermittent, generalized pain that they may
describe as indigestion and pain in their neck, jaw, throat, shoulder, or back (Osborn et al., 2014). Patients are
diagnosed with a STEMI after an EKG which shows ST elevation and elevated cardiac blood markers such as
troponin T or I, CK-MB, or CK total. Treatment includes cardiac catheterization and stent placement
(sometimes), medications such as nitrate therapy, beta blockers, and ACE inhibitors ((Osborn et al., 2014). Risk
factors for MI are modifiable and non-modifiable including smoking, heredity, obesity, hypertension,
hyperlipidemia, physical inactivity, diabetes, increasing age, and male gender (Osborn et al., 2014).

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: Aspirin Concentration (mg/ml): Tablet Dosage Amount (mg): 81 mg
Route: PO Frequency: Once daily
Pharmaceutical class: Salicylate Home Hospital or Both
Indication: Prophylaxis of transient ischemic attacks and MI
Side effects/Nursing considerations: Dyspepsia, epigastric distress, nausea, GI bleeding, rash

Name: Atorvastatin (Lipitor) Concentration: Tablet Dosage Amount: 80 mg

Route: PO Frequency: At bedtime
Pharmaceutical class: Hmg coa reductase inhibitors Home Hospital or Both
Indication: Primary prevention of coronary heart disease in asymptomatic patients w/ increased total and LDL cholesterol and decreased HDL
cholesterol
Side effects/Nursing considerations: Abd cramps, constipation, diarrhea, flatus, heartburn, rash
Monitor liver function tests, notify provider if unexplained muscle pain, tenderness or weakness occurs.

Name: carvedilol (Coreg) Concentration: Tablet Dosage Amount: 3.125 mg

Route: PO Frequency: BID
Pharmaceutical class: Beta Blocker Home Hospital or Both
Indication: HTN
Side effects/Nursing considerations: Dizziness, fatigue, weakness, diarrhea, erectile dysfunction, hyperglycemia.
Take apical pulse before administering, if <50 bpm withhold and notify provider

Name: Ticagrelor (Brilinta) Concentration: Tablet Dosage Amount: 90 mg

Route: PO Frequency: BID
Pharmaceutical class: Platelet aggregation inhibitor Home Hospital or Both
Indication: Decrease the incidence of thrombotic cardiovascular events associated w/ ACS.
Side effects/Nursing considerations: Dyspnea, bradycardia, bleeding, gynecomastia
University of South Florida College of Nursing Revision August 2013 3
Inform pt that they will bleed and bruise more easily and it will take longer to stop bleeding, discontinue 5 days prior to planned surgical procedures

Name: Heparin Concentration: Units Dosage Amount: 100 units/mL

Route: IV line flushing Frequency: Flush
Pharmaceutical class: Anticoagulant/antithrombotic Home Hospital or Both
Indication: Prophylaxis & treatment of various thromboembolic disorders
Side effects/Nursing considerations: Anemia, bleeding, thrombocytopenia

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? 2g Na+ Analysis of home diet (Compare to My Plate and
Diet Pt follows at home? Regular Consider co-morbidities and cultural considerations):
MyPlate suggests that the patient should eat 5 oz of grains,
2 cups of vegetables, 1.5 cup of fruits, 3 cups of dairy, and
5 oz of protein daily.
24 HR average home diet: With an average 2000 calorie diet, the pt does not meet his
Breakfast: I do not ever eat breakfast. daily caloric intake. His protein intake is adequate but the
rest of his food group intake percentages are on under the
Lunch: Sandwich with meat, mayonnaise, tomato, & oil. recommended amount. A recommendation specific to this
chips, sweet tea patient would be to consume breakfast and increase his
fruit and dairy intake.
Dinner: Something different every night but it usually
consists of meat, veggies, pasta/rice, and milk to drink.
Snacks: Cereal bars, ice cream for dessert

Liquids (include alcohol): Sweet tea, soda occasionally,

water, 2% milk w/ chocolate or strawberry syrup
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.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? I am never ill.

How do you generally cope with stress? or What do you do when you are upset? I am vocal about it, I voice my concern
then I let it roll of my back and move on.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life):
None, just really bored in this hospital.

+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? At times as a child.

Have you ever been hit punched or slapped? Yes, as a child by my parents
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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? X

Are you currently in a safe relationship? Yes, marriage.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame
Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion/Diffusion 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 generativity vs stagnation stage is said to be experienced by individuals
between the ages of 40 and 65 years old, but, Erikson said that anyone can regress or skip stages due to life events.
The goal of this stage is to be creative and productive. Often this is accomplished through work or relationships.
The person who fails to achieve generativity may manifest stagnation in the form of superficial relationships and
self-absorption (Treas, Wilkinson, 2014).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
Generativity vs stagnation is usually the stage for people between the ages of 40 and 65. My patient is 50 years old
and I believe he is portraying characteristics to both generativity and stagnation. Although he never had children,
he is married and has a good, steady job. He told me that he hasnt called out of a job in his entire career history
until he was forced to this week. He said he and his wife have a healthy marriage and they spend time doing things
they enjoy together. On the other hand, the patient is a bit self-absorbed; he doesnt seem to be very sensitive to
others and he isnt willing to even consider making lifestyle changes to improve his health.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patient doesnt really seem to have comprehended what happened yet. He is just anxious to get out of the
hospital and smoke a cigarette. I would like to believe that once he is discharged, he will be willing to make some
lifestyle changes and he will progress forward into the generativity stage.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I dont know, I know you are going to say smoking just like
everyone else but I dont agree with that and like I said before, the doc said I have a massive heart attack but I still
dont believe him.

What does your illness mean to you? I guess as an eye opener and possibly a different perspective on life.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)

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? No
Have you or your partner received the Gardasil (HPV) vaccination? No

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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 have been married for a long time, I dont worry about that.
How long have you been with your current partner? Over 25 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

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life? Not much importance, Id say like 30%. I do not
attend church.

Do your religious beliefs influence your current condition? No

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
How much? 1-2 packs a day which For how many years?
If so, what? Cigarettes
is 20 to 40 cigarettes Over 30 years
(age 18 thru current)

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patients household smoke tobacco? If

Has the patient ever tried to quit? Yes, a couple of times.
so, what, and how much? No, just the patient

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? He does not drink anymore How much? (give specific volume) For how many years? Like 5
Once every 6 months to a year (if
(age 20 thru 25)
that) only on occasion

If applicable, when did the patient quit? Mid

20s

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what? Marijuana
For how many years? Not long, my
How much? N/A
younger days.
(age thru )

Is the patient currently using these drugs? If not, when did he/she quit?
Yes No Early 80s

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks: Not that I know of,
possibly in the military.

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 10 REVIEW OF SYSTEMS
General Constitution Gastrointestinal Immunologic
Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: 50 or 60 Diverticulitis Life threatening allergic reaction
Bathing routine: Daily Appendicitis had appendix removed Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? 2010
HEENT Other: Hematologic/Oncologic
Difficulty seeing wears glasses Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections every once in awhile hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: AB-
Post-nasal drip Normal frequency of urination: 6-8x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 1-2x/day Diabetes Type:
Routine dentist visits Never Hypothyroid /Hyperthyroid
Vision screening Never Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing - Occasionally Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
Last CXR? Yesterday menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? 2010 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? Today Arthritis Chicken Pox
Other: Other: Other:

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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:(Describe abnormal assessment below non checked boxes)
General Survey: Pt is a 50 yo Height: 56 Weight: 145 BMI: 23.4 Pain: (include rating & location):
male who is alert & oriented Pulse: 96 Blood 0/10
X3. Pressure: 99/77
Temperature: (route taken?) Respirations: 16 (include location) Left brachial
98.5 oral SpO2: 98% 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 talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
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

Peripheral IV site Type: 20g Location: Right FA Date inserted: 10/12/2015

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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- 2 inches & left ear- 2 inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:

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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
Lung sounds clear but diminished from apices to bases
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 Sputum production not witnessed
D Diminished
S Stridor
Ab - Absent

Cardiovascular: No lifts, heaves, or thrills PMI felt at: MCL 5th ICS
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): I did not get an ECG strip

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: N/A Popliteal: N/A DP: 3 PT: N/A
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/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: Yellow Previous 24 hour output: N/A mLs N/A
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10/13/2015) 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 Not assessed, patient alert, oriented, denies problems
Other Describe:

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at 5 RUE _______5 LUE _______5 RLE & _______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 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: Biceps: Brachioradial: Patellar: Achilles: Ankle clonus: positive negative Babinski: positive negative
Reflex hammer unavailable so I was unable to obtain DTR.

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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

WBC The patients WBC are in Number of infection
15.1 H 10/12/2015 (admission) the high range but they fighting cells. High WBC
are trending downward. indicates the presence of
13.5 H 10/13/2015 an infection or
Normal (4.5-11) inflammation. The patient
was on Vancomycin so it
seems to be working.
RBC Upon admission, pts RBC RBCs are usually a little
4.76 10/12/2015 (admission) was normal, after surgery bit low after surgery
his RBC was a little low. because the patient loses
3.90 L 10/13/2015 blood.
Normal (4-5.2)
HGB Upon admission, HGB If the RBC and the HCT
14.2 10/12/2015 (admission) was within normal limits. are low, HGB is expected
After surgery, it got a to be low as well.
11.2 L 10/13/2015 little low.
Normal (13-18)
HCT Upon admission, HCT Low HCT may indicate
41.6 10/12/2015 (admission) was within normal limits. anemia or over-hydration.
After surgery, it got a The patient was given IV
34.2 L 10/13/2015 little low. fluids while in surgery
Normal (35-47%) and he also lost blood
which would explain the
low RBC, HGB, and
HCT results.
Platelet Platelets are normal. Important when
184 10/12/2015 (admission) monitoring drug therapy
such as anticoagulants.
174 10/13/2015
Normal (150-400)
Glucose Glu is normal. Abnormal glu can
75 10/12/2015 (admission) indicate diabetes or some
medications can affect glu
90 10/13/2015 levels.
Normal (70-100)
Sodium Na is normal. Pt does not have a sodium
137 10/12/2015 (admission) or water imbalance.
 139 10/13/2015
Normal (135-145)
Potassium K is normal. K is normal.
3.8 10/12/2015 (admission)

3.6 10/13/2015
Normal (3.5-5.0)
BUN Upon admission, the Increased BUN and
22 H 10/12/2015 (admission) BUN was a little elevated creatinine levels may
but it is trending down. indicate fluid
20 10/13/2015 retention/decreased renal
Normal (6-20) output.
Creatinine The creatinine is a little Creatinine assesses renal
1.3 H 10/12/2015 (admission) elevated upon admission function, high levels may
and seems to be lingering indicate renal disease.
1.4 H 10/13/2015 at that level.
Normal (0.6-1.3)
Troponin Troponin I level was An elevated troponin
30.67 10/12/2015 (admission) elevated upon admission. level indicates that there
damage to the heart,
Normal (<0.05 ng/mL) which is correct b/c pt
had an acute ST elevation
MI.

++2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu-checks, etc. Also provide rationale and frequency if applicable.)
Pt is to remain on the 2g Na+ diet (heart diet) and vitals should be checked Q4H. Pt is currently on the
floor for observation and the provider is considering discharging him in a day or two. There arent any
scheduled diagnostic tests besides labs.

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

1. Decreased cardiac output r/t dysrhythmias secondary to acute myocardial ischemia and infarction AEB ST
elevation.

2. Ineffective denial r/t lack of competency in using effective coping mechanisms AEB patients statement, I still
dont believe I had a heart attack, and I am not going to quit smoking.

3. Activity intolerance r/t imbalance between myocardial oxygen supply and demand AEB alterations in heart rate and
BP with activity.
 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t dysrhythmias secondary to acute myocardial ischemia and infarction AEB ST elevation.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day care is
Goal Provide References Provided
Patient will demonstrate adequate Recognize primary characteristics If characteristics of decreased Partially met. Pt was hypotensive
cardiac output as evidenced by BP, of decreased cardiac output as cardiac output are recognized, but all other vital signs were stable
pulse rate, and rhythm within fatigue, dyspnea, edema, treatment can begin sooner than and within normal parameters for
normal parameters for patient; orthopnea, paroxysmal nocturnal later (Ackley et al, 2014). patient.
strong peripheral pulses; dyspnea, and increased central
maintained level of mentation, lack venous pressure.
of chest discomfort or dyspnea, and
adequate urinary output by the end
of the shift.
Patient will demonstrate an ability Administer oxygen as needed per Oxygen should be administered to Met. Patient was up and walking
to tolerate activity without physicians order. relieve symptoms of hypoxemia around most of the day.
symptoms of dyspnea, syncope, or (Ackley et al, 2014).
chest pain by the end of the shift.
Patient will remain free of side Provide a restful environment by Rest helps lower arterial pressure Met. Patient did not demonstrate
effects from medications used to minimizing controllable stressors and reduce the workload of the any side effects/adverse effects to
achieve adequate cardiac output and unnecessary disturbances. myocardium by diminishing the any medications. He tolerated all
throughout the shift. Schedule rest periods after meals requirements for cardiac output meds well.
and activities. (Ackley et al, 2014).
Patient will explain actions and Monitor vital signs. Vital signs and labs are viable Not met. Patient does not believe
precautions to prevent primary or resources to show if a client is in smoking has anything to do with
secondary cardiac disease by the distress his illness and he does not plan to
end of the shift. stop. He also does not believe he
had a heart attack.
Check BP, pulse, and condition It is important to evaluate how the
before administering cardiac patient is tolerating current
medications. Notify provider if HR medications (Ackley et al, 2014).
or BP are low before holding
medications.
Watch laboratory data closely. Routine lab work can provide
insight into the etiology of heart
disease and extent of
 decomposition (Ackley et al,
2014).
Keep patients diet consistent with Sodium restricted diets help
physicians order (sodium restricted decrease fluid volume excess. Low
diet). Serve small, frequent, saturated fat diets help decrease
sodium-restricted, low-saturated fat atherosclerosis (Ackley et al, 2014)
meals.
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 appts Pt will need to follow up with his primary care doctor as well as his cardiologist in 1 week.
Med Instruction/Prescription Pt was not taking any medications prior to his hospitalization but he will be going home with a whole set of
new medications.
are any of the patients medications available at a discount pharmacy? Yes No Unknown
Rehab/ HH
Palliative Care
 15 CARE PLAN
Nursing Diagnosis: Ineffective denial r/t lack of competency in using effective coping mechanisms AEB patients statement, I still dont believe I
had a heart attack, and I am not going to quit smoking and abruptly discontinuing medications in the past.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Interventions on
Goal Provide References Day care is Provided
By the time of discharge, pt will Assess the patients and familys Effective communication between Not met. The patient has not even
understand the consequences of understanding of the illness, all parties is important for optimal considered quitting smoking since
smoking and that it is a risk factor treatments, and expected outcomes. health outcomes ((Ackley et al, his heart attack occurred and he is
for further health issues. 2014). upset that he cannot smoke while in
the hospital.
Pt will display appropriate affect Allow patient time for adjustment Health care providers can assist Not met. Pt states that he does not
and verbalize fears by the end of to his situation. patients in developing effective have any fears related to his illness
the shift. modes of adjustment to their illness and is having a hard time believing
(Ackley et al, 2014). his diagnosis.
Pt will understand importance of Spend time with the patient, listen Clinician-patient communication Met. Pt has been taking his
taking medications as prescribed. and allow time for response. has been shown to be a medications without hesitance and
determining factor in health has an understanding about each
outcomes (Ackley et al, 2014). one.
Avoid confrontation and consider The patient is the primary decision
the patient as an equal partner in maker in his health care (Ackley et
health care. al, 2014).
Explain the necessity of adherence Patients need to understand the
to the prescribed treatment plan to consequences of noncompliance to
promote feelings of wellness. treatment plans.
Teach family members that denial Family members need to be the
may continue throughout the patients support but do not want to
adjustment to treatment and they overwhelm them in their process of
should not be confrontational. adjustment and understanding.
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 appts Pt will need to follow up with his primary care doctor as well as his cardiologist in 1 week.
Med Instruction/Prescription Pt was not taking any medications prior to his hospitalization but he will be going home with a whole set of
new medications.
are any of the patients medications available at a discount pharmacy? Yes No Unknown
Rehab/ HH
Palliative Care
 References

Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (Tenth ed., pp. 179-183 & 292-295). Maryland Heights, MO: Elsevier
Mosby.

Nursing Central. (2015). Unbound Medicine Inc. (Version 1.25) [software]. Available from
http://nursing.unboundmedicine.com/nursingcentral/ub/index/Davis-Lab-and-Diagnostic-
Tests/All/A

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (Eds.) (2014). Medical-Surgical
Nursing Preparation for Practice (2nd ed., pp. 948-950). Upper Saddle River, New
Jersey: Pearson.

Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning (p. 164).
Philadelphia, PA: F.A. Davis Company.

U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC. Daily Food

Plans. http://www.choosemyplate.gov/tools-supertracker. Accessed November 12, 2015.