UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Stacy Dunham

PATIENT ASSESSMENT TOOL . Assignment Date: 11/19/15

1 PATIENT INFORMATION Agency: SMH
Patient Initials: RP Age:76 Admission Date: 10/27/15
Gender: M Marital Status: Married Primary Medical Diagnosis with ICD-10 code:
Primary Language: English Cardiac Arrest I46.9
Level of Education: 2 years Community College Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?):Liquid Flow Meter Rep - Retired MI
Number/ages children/siblings: 4 children. 38F, 54M, 52M, 50M

Served/Veteran: Never Code Status: Full Code

Living Arrangements: Lives with his spouse. His wife will take care of Advanced Directives: Yes
him and she is healthy and doesnt have Alzheimers. They live in a If no, do they want to fill them out?
house with no stairs. Surgery: 11/4/15 implantable cardioverter-defibrillator
Culture/ Ethnicity /Nationality: German and Spanish, White, American
Religion: Catholic Type of Insurance: Medicare / BCBS

1 CHIEF COMPLAINT:
He states he was standing outside his house and began to feel woozy. He walked into his house for some OJ as he thought his
BS was low. He states he went down to his knees and waited on the floor for
a few minutes and drank the juice. He was still feeling woozy, so he took his BP and pulse. His BP was WNL, but his
HR was 160. He had his wife drive him to the ED. He states he felt fine prior to the sudden onset of symptoms .

3 HISTORY OF PRESENT ILLNESS:

Patient was admitted into ED for tachycardia. He was cardioverted three times with no change. Shortly thereafter he was in
acute respiratory failure and was intubated when his BP was severely hypotensive. He then coded 5 times. His initial rhythm
was V-fib and he was defibrillated with no change. CPR performed and with the use of epi, he was resuscitated and admitted
into the ICU. A pacemaker/defibrillator was placed and the patient is now due to be discharged today.
O: 1pm
L: Global
D: He thinks approx. 1 hr until he went into cardiac arrest
C: Felt woozy, uneasy, weird
A: walking made it worse, but nothing made it better
R: No radiation
T: Sudden
S: 8/10
He currently is asymptomatic. He states he has no pain anywhere, no belching, bloating, gas, dyspnea, diarrhea, dizziness, h/a,
CP, palpitations. He states hes not as strong as he was before being hospitalized, but hes feeling well.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date Operation or Illness
1998 CABG x 3
2005 8 cardiac stents
2006 RC repair bilat
2012 Renal and iliac stent
MI, CAD, ischemic heart disease, PVD, CKD, DMII, neuropathy, HTN, hyperlipidemia, CHF, obesity,
sleep apnea, COPD patient doesnt know the details as to when he was diagnosed with any of these or
when he began the medications. He states theyve all been going on a long time.

2 FAMILY MEDICAL HISTORY

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
Alcoholism

Glaucoma
Cause

Problems

Problems
Allergies

Diabetes

Seizures
Arthritis
Anemia

Asthma

Kidney
Cancer

Tumor
of

Stroke
Gout
Death

Father 78 Unk
Mother 78 MI X
Brother 72 Living X X
Sister 83 living X X
Other

Other

Other

Comments, and include date of onset: UNK

He states he didnt have much contact with his father and didnt have a close relationship with his siblings. He also never met his
grandparents. He states he doesnt know much about the medical hx of his family.

1 IMMUNIZATION HISTORY
(May state U for unknown, except YES NO
Routine childhood
for Tetanus, vaccinations
Flu, and Pna) X - 1940
Vaccinations for military or federal service X
Adult Diphtheria (Date) X - UNK
Adult Tetanus (Date) X 2-3 yrs
Influenza (flu) (Date) X 10/1/15
Pneumococcal (pneumonia) (Date) X 01/15
Vaccines for intl travel or occupational purposes? X

1 ALLERGIES OR ADVERSE REACTIONS

NAME Type of Reaction (describe explicitly)
Medications: NONE N/A
Other (food, tape, latex, dye, etc.) NONE N/A

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 5 PATHOPHYSIOLOGY: Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any genetic factors
impacting the diagnosis, prognosis or treatment, and include APA reference and in text citations.
Coronary Artery Disease (CAD): CAD causes about one out of every six deaths in the United States, making it the
single largest killer of the American population (Osborn, Wraa, Watson, Holleran, 2010). With this disease, its a
narrowing of the coronary arteries and usually occurs due to a build-up of plaque from cholesterol, lipids, and calcium
deposits. These deposits and subsequent narrowing (stenosis) will in turn cause reduced blood flow and oxygen to the
heart. If deposits continue to build-up it could cause a complete blockage, which leads to an infarction of the heart. The
heart gets the majority of its oxygen directly from the coronary arteries. If oxygen demand isnt met due to narrowing and
demand then blood flow must be increased. However, due to the patients history of CAD and atherosclerosis, his arteries
werent able to compensate and increase blood flow. This disease itself progresses slowly over many years and has many
contributing factors; the development of this disease and how fast it progresses is directly related to the patients health
history. High levels of total serum cholesterol and LDL (hyperlipidemia) combined with low levels of HDL (good fats)
is just one example of the cause of this disease. However, this patient has several cardiac risk factors which also
contributed to atherosclerosis and CAD, which are: a strong family history of CAD, his gender, age, obesity, sedentary
lifestyle, and twenty-five years of tobacco abuse, HTN, DM II, and chronic kidney disease. Some of the contributing
factors of CAD arent controllable, like age, gender, race, and family history, however, there are ways to stop the disease
from worsening or progressing faster than it potentially could, such as: eating a diet low in fat and cholesterol, exercising,
and not smoking. If the disease has already progressed and the patient isnt living a healthy lifestyle, there are
pharmaceutical ways to help slow the progression by taking anti-hypertensives, lipid lowering agents, and controlling
glucose levels related to diabetes. While this patient had stopped smoking years prior, the damage to his body had already
been done due to a prolonged unhealthy lifestyle. Other treatments depending on the stage of the disease include: oxygen,
medications for rate control including: beta blockers, calcium channel blockers, and/or antiarrhythmics, anticoagulants,
cardiac catherization, coronary angiography, PCI, and a pacemaker.

The prognosis of this patient isnt a good one. He has an ejection fraction rate of less than 35% which increases his risk of
arrhythmias and sudden cardiac arrest. He did however have surgery for an implantable cardioverter defibrillator, but
even that can only do so much. This patient will likely never fully recover due to his comorbidities, the severity of his
condition, and inability to exercise due related to exertional dyspnea.

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All medications cited by: (Unbound Medicine, Inc, 2015).
5 MEDICATIONS: (Include both prescription and OTC; home reconciliation, routine, and PRN. Give trade and generic name.)
Name: Actos (pioglitazone) Concentration (mg/ml): 30mg Dosage Amount (mg): 1 tablet
Route: oral Frequency: once daily
Pharmaceutical class: thiazolidinedione Home
Indication: DMII
Side effects: CHF, liver failure, bladder cancer, rhabdomylolysis, edema, macular edema, anemia. Nursing considerations: Observe for
symptoms r/t hypoglycemia, fluid retention, jaundice; perform regular labs and watch for increasedAST and ALT, decreased H&H. Instruct to
take as directed and dont double dose if they miss it. Explain this does not cure diabetes, it only treats it. Discuss signs of
hypo/hyperglycemia and hepatic dysfunction and to notify physician if they have any signs of them; advice to always carry some form of
sugar with them in case of hypoglycemia; encourage following diet and try to exercise.

Name: Aspirin (acetylsalicylic acid) Concentration: 81mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: salicylate Both
Indication: decrease platelet aggregation
Side effects: GI bleeding, anaphylaxis, laryngeal edema, anemia, epigastric distress, nausea, hepatotoxicity. Nursing considerations:
Consider patients with allergies and asthma are at risk for developing hypersensitivity reactions. Advise the patient to report unusual bleeding
of the gums, black tarry stools, increased bruising, and tinnitus. Advise the patient to avoid concurrent use of alcohol to minimize gastric
distress.

Name: Coreg (carvedilol) Concentration: 25mg Dosage Amount: 1 tablet

Route: oral Frequency: twice daily
Pharmaceutical class: beta blocker Both
Indication: HTN / CHF
Side effects: bradycardia, worsening HF, pulmonary edema, SJS, toxic epidermal necrolysis, anaphylaxis, angioedema, hyper/hypoglycemia,
myalgia, erectile dysfunction. Nursing considerations: Take apical pulse before administering and do not give if HR below 50. Advise the
patient to follow a low sodium diet. Advise the patient to take as directed and dont double if they miss a dose. Advise not to abruptly stop
taking as it may cause arrhythmias or HTN. Instruct the patient on how to take their pulse and not to take if the pulse is less than 50. Advise
to change positions slowly to reduce changes of orthostatic hypotension. Advise they should monitor BS as it could cause changes. Advise to
notify physician if they have respiratory issues, cold hands and feet, dizziness, bleeding or increased bruising as this may indicate a more
serious problem. Advise this treats HTN and doesnt cure it. Discuss need to change diet, decrease alcohol consumption, cessation of
smoking, restrict sodium, and begin exercise regimen.

Name: Amaryl (glimperide) Concentration: 2 mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: sulfonylurea Home
Indication: DMII
Side effects: hypoglycemia, hyponatremia, anemia, blood dyscrasias, N&V, diarrhea, hepatitis, dizziness, photosensitivity. Nursing
considerations: Instruct to take as directed and dont double dose if they miss it. Explain this does not cure diabetes, it only treats it. Discuss
signs of hypo/hyperglycemia and hepatic dysfunction and to notify physician if they have any signs of them; advice to always carry some form
of sugar with them in case of hypoglycemia; encourage following diet and try exercising. Notify physician if they have unusual weight gain,
edema, dyspnea, myalgia, weakness, or signs of bleeding.

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Name: Zetia (ezetimibe) Concentration: 10mg Dosage Amount: 1 tablet
Route: oral Frequency: once daily
Pharmaceutical class: cholesterol absorption
Home
inhibitor
Indication: hyperlipidemia
Side effects: Angioedema, cholecystitis, cholelithiasis, increased liver enzymes, nausea, and pancreatitis. Nursing considerations: Obtain
diet hx and fat consumption. Evaluate serum cholesterol and triglycerides before initiating. Advise them to take the medication as directed and
at the same time every day. Advise the patient should follow a low fat diet. Advise they should notify physician if they have myalgia or
weakness. Instruct them to follow up with physician for labs regularly.

Name: Plavix (clopidogrel) Concentration: 75mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: platelet aggregation
Home
inhibitor
Indication: reduce thromboembolism events
Side effects: GI bleeding, bleeding, blood dyscrasias, myalgia, CP, edema, HTN. Assess the patient for signs of CVA, PVD, and MI.
Nursing considerations: Monitor bleeding time, CBC with differential and platelet count, as well as AST and ALT. Advise them to take the
medication as directed and at the same time every day. Advise the patient to report unusual bleeding of the gums, black tarry stools, increased
bruising, and tinnitus. Advise the patient to avoid concurrent use of alcohol to minimize gastric distress. Patient to notify physician if they
have fever, chills, sore throat, rash, unusual bleeding or increased bruising as this may indicate a more serious problem.

Name: Apresoline (hydralazine) Concentration: 85mg Dosage Amount:1 tablet

Route: oral Frequency: three times daily
Pharmaceutical class: vasodilator Both
Indication: HTN and CHF
Side effects: tachycardia, CP, arrhythmia, edema, orthostatic hypotension, sodium retention, myalgia, N&V, and diarrhea. Nursing
considerations: Monitor BP and pulse. Take apical pulse before administering and do not give if HR below 50. Monitor CBC, and serum
electrolytes. Advise the patient to follow a low sodium diet. Advise they should weight themselves regularly and assess their limbs for
edema. Advise the patient to take as directed and dont double if they miss a dose. Advise not to abruptly stop taking as it may cause
arrhythmias or HTN. Instruct the patient on how to take their pulse and not to take if the pulse is less than 50. Advise to change positions
slowly to reduce changes of orthostatic hypotension. . Advise to notify physician if they have edema, fever, myalgia or joint aching, or
increased fluid retention in the limbs as this may indicate a more serious problem.

Name: Dermadex (torsemide) Concentration: 20mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: loop diuretic Home
Indication: edema due to HF, renal disease, and HTN
Side effects: SJS, toxic epidermal necrolysis, increased BUN, hypotension, hyperglycemia, tinnitus, dyspepsia, electrolyte imbalances, and
myalgia. Nursing considerations: Monitor daily weight, BP, and pulse during administration. Monitor serum electrolytes, AST and ALT,
BUN creatinine, uric acid, serum glucose, I&O, lung sounds, skin turgor, skin rash, tinnitus and for edema. Assess for allergy to
sulfonamides. Advise the patient to follow a low sodium diet and consult dietitian. Advise they should weight themselves regularly and
assess their limbs for edema. Advise the patient to take as directed and dont double if they miss a dose. Advise to change positions slowly
and to monitor BS regularly as it may cause hyperglycemia. Have patients use sunscreen while taking this medication. Advise this treats
HTN and doesnt cure it. Discuss need to change diet, decrease alcohol consumption, cessation of smoking, restrict sodium, and begin
exercise regimen.

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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? Renal diet Co-morbidities/cultural considerations: CAD, HTN, hyperlipidemia, DMII, CHF,
Diet patient follows at home? Tries to limit Na+, K+, and CKD, obesity
sugar.
24 HR average home diet: 1225 calories
Protein
Breakfast: 1 bowl of Kellogs corn flakes or Cheerios (1 c) Grains Vegetables Fruits Dairy
Foods
Lunch: 1 sandwich on rye bread. Usually Boars Head
Low sodium ham (4oz.) with 1 slice of American cheese with Target 6 oz. 2 cup(s) 2 cup(s) 3 cup(s) 5 oz.
either no condiments or occasionally mustard. Eaten 6 oz. cup(s) 0 cup(s) 1 cup(s) 7 oz.
Dinner: Pork or beef roast (7oz.) with canned corn or green
beans (1/2 c) and white rice (1 c). Status Ok Under - Under Over
Snacks: none Allowance: 2000 calories Eaten: 1150 Remaining: 850
Liquids (include alcohol): approx. 80 Oz of water, 1 16 oz. Empty calories eaten: 153
diet Pepsi daily, 1 8 oz. cup of coffee with creamer and sweet Oils limit: 6 tsp., Eaten: 0 tsp.
and low. Sat Fat limit: 22 g, Eaten: 13g
Sodium limit: 2300mg, Eaten: 2395mg
(ChooseMyPlate.gov. 2011)
Renal Diet: 4 oz. dairy, 8 oz. protein, 2g K+, 2g Na+, 800mg P
NOTE: He is not consuming enough calories or the right types Recommendation: Maintain a healthy lifestyle verses going on a diet, so he is more likely
of food. He is consuming too much NA+, protein, and dairy to keep it up. Consult a dietician regarding a renal/cardiac/diabetic diet and see if they can
per day for someone with CKD, and he isnt consuming any provide take home paperwork showing the types of food to eat, and what foods fit into
good fats or fruit. what category. Begin cooking with fresh vegetables instead of canned and begin
consuming good fats. Consume 1 daily serving of fruit a day. Decrease the amount of
Na+ and protein he is consuming. She needs to decrease it by 1.5g daily. Consult his
physician on how much H2O he is consuming and whether he is drinking too much, as
this can cause complications with CHF and the medications he is on. CHF/CKD can be
greatly affected by electrolyte imbalances, and also contributes to HTN. He is likely
retaining too much water, which can affect his CHF and cause fluid accumulation in the
lungs and/or body. He needs to increase the amount of grains and fiber, which will help
with constipation. A poor diet will contribute to lethargy and weakness and slow healing.
Improving his diet by eating the right types of food will likely improve his cholesterol
levels, HTN, GERD, and symptoms of CHF. His decreased appetite may be due to
depression or worsening health, but his health could be improved with a better diet. He
may also need to begin supplements which may make it easier for him to get the nutrients
he needs.

1 COPING ASSESSMENT/SUPPORT SYSTEM

Who helps you when you are ill? His wife
How do you generally cope with stress, or what do you do when you are upset? He states he rarely gets stressed and he is
usually able to cope and deal with it. When he does get stressed, he states he takes time for himself and tends to stay away from
others. He tries to decompress.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)? He states he
hasnt felt depressed or overwhelmed, but he has been aggravated since being hospitalized. He states he is learning to cope with
his medical problems, but he is more worried about his wife and how shes feeling.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? Yes, occasionally over the years when he would have arguments with his children.
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? N/A
Are you currently in a safe relationship? Yes

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 4 DEVELOPMENTAL CONSIDERATIONS: Eriksons stage of psychosocial development
Check one box and give the textbook definition (citation and reference) of both parts of Ericksons developmental stage
in the patients age group: Ego Integrity vs. Despair Age: 65+ years
Textbook definition of Stage 8: The task of this stage is the acceptance of ones life, worth, and eventual death. Ego integrity
reflects a satisfaction with life and an understanding of ones place in the life cycle. A sense of loss, discomfort with life and
aging, and a fear of death are seen in despair. (Treas & Wilkinson, 2014)
Describe the stage and give the characteristics that the patient exhibits: The patient appears to teeter between these two
stages. The patient he is not in good health and he has declined over the last few years, but he doesnt seem to accept (or at least
doesnt verbalize) death is likely very close. He doesnt appear depressed, but more frustrated with his health and he
understands there is a lot he is unable to do, such as going for a walk. He states his family is the most important thing in life
and desires to spend more time with family, but he seems to have regret or a sense of loss over not being closer with his
children. When he refers to family, he is referring to his wife and his grandchildren. He is however able to spend time with his
grandchildren. He does express some fear over what would happen to his wife if something happened to him.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: Dying
and being resuscitated 5 times has made him more appreciative. It has also made him realize he cannot continue to put off his
health and recommendations from his physicians. At the same time, I think he now realizes just how fleeting life can be and if
he could die 5 times in 1 day, it could happen again.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: Stupidity on my part. He states he was told by his cardiologist more than a
year ago that he would need a pacemaker, but he kept putting the surgery off. He states he didnt believe it was really necessary
and that his medical problems were as serious as they were.
What does your illness mean to you? He understands he is going to have to do things differently. He states hes going to
have to alter his diet, exercise, take his medications regularly, and make all of his follow-up appointments with his physicians.
He states he also knows hes going to have to do rehab after the surgery, of which he isnt looking forward to but knows its
necessary.

+3 SEXUALITY ASSESSMENT:
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? Not that he is aware of.
Have you or a partner ever had an abnormal pap smear? Not that hes aware of.
Have you or your partner received the Gardasil (HPV) vaccination? Hes not sure what that is, so he says no.
Are you currently sexually active? No, not for a few years. He states he hasnt had the energy or endurance.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? I dont have to worry about that anymore.
How long have you been with your current partner? 20 years
Have any medical or surgical conditions changed your ability to have sexual activity? Cardiac problems and getting
winded easily.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No, since hes not sexually active.

1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life? Its important to him and he prays daily. He states he
mostly prays for friends and family. He use to attend a catholic church for most of his life, but approx. 22 years ago he stopped
going to church after they denied him getting married in church, due to prior divorce. He is still angry he was rejected by the
church he had invested so much into.
Do your religious beliefs influence your current condition? Yes, he feels like it gives him life and the energy to stay alive.

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

1) Smoking:
Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes
If so, what? Cigarettes
How much? 1 pack daily
For how many years? 25 years
(age: 16 thru: 31) then picked it up again at (age: 56 thru: 66)
Pack Years: 25
If applicable, when did the patient quit? 1970 and again in 2005
Does anyone in the patients household smoke tobacco? His wife smokes cigarettes pack daily.
Has the patient ever tried to quit? Yes, see above.

2) Alcohol:

Does the patient drink alcohol or has he/she ever drunk alcohol? He has drunk before, but he states hes never been a big
drinker.
What? Seagrams whiskey and 7UP How much? 8 oz. For how many years? 51 (age: 25 thru: current )
If applicable, when did the patient quit? He never did, but he states he only drinks 1-2 times a year.

3) Drugs:

Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No If so, what? N/A
How much? N/A For how many years? N/A (age: n/a thru: n/a)
Is the patient currently using these drugs? No If not, when did he/she quit? N/A

4) Hazards:

Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks? He worked around
gasoline and various chemicals for approx. 47 years due to his job.

10 REVIEW OF SYSTEMS
General Constitution Gastrointestinal Immunologic
Recent weight loss or gain Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary X Constipation Irritable Bowel Night sweats
X Changes in appearance of skin - DRY X 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: NONE Diverticulitis Life threatening allergic reaction
Bathing routine: ONCE DAILY, SHOWER Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
X Last colonoscopy? WITHIN 5 YEARS
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
X Cataracts HAD REPAIRED X nocturia TWICE NIGHTLY Bleeds easily
Difficulty hearing Dysuria X Bruises easily
Ear infections Hematuria X Cancer - PROSTATE CANCER 2011
Sinus pain or infections Polyuria Blood Transfusions
Nose bleeds Kidney stones Blood type if known: unk

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 Post-nasal drip Normal frequency of urination: 10 x/day Other:
Oral/pharyngeal infection X Bladder or kidney infections UTIs
Dental problems Metabolic/Endocrine
X Routine brushing of teeth 2x/day X Diabetes Type: II
X Routine dentist visits 1 x/year Hypothyroid /Hyperthyroid
X Vision screening 2 x/year Intolerance to hot or cold
Other: no glasses or cataracts X Osteoporosis
Other:
Pulmonary
X Difficulty Breathing Central Nervous System
X Cough dry xs few weeks or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia X Dizziness o/o prior to cardiac arrest
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
X Last CXR? 11/04/15 menopause age? Meningitis
Other: COPD (?) uses O2 PRN, CPAP night Date of last Mammogram &Result: Other:
DEXA Result: OSTEOPOROSIS 2015
Cardiovascular M EN ONLY Mental Illness
X Hypertension Infection of male genitalia/prostate? Depression
X Hyperlipidemia Frequency of prostate exam? Schizophrenia
X Chest pain / Angina Date of last prostate exam? Anxiety
X Myocardial Infarction X BPH Bipolar
X CAD/PVD Urinary Retention Other:
X CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
X Arrhythmias Vtach, Vfib Osteomyelitis Scarlet Fever
X Last EKG screening, when? 10/27/15 X Arthritis Chicken Pox
Other: Pacemaker 11/04/15 Other: old FX Lt wrist approx. 10 years ago Other:
CAROTID STENOSIS
Is there any problem that is not mentioned that your patient sought medical attention for with anyone? Trigger finger RT hand ring finger and sleep
apnea. Otherwise have just had routine check-ups.

Any other questions or comments that your patient would like you to know? Yes. He states this is a blanket statement for all. He states people in
health care should listen to their patients, specifically him, regarding his medical care. He states he should have input in his care and it seems all too often
he isnt heard or acknowledged. He states he also gets aggravated when he has to wait for care. EX: he was placed on the bedside commode and left there
for 45 minutes; he called for someone to help him a 2nd time to the commode, and it took 20 minutes for someone to come. He states he soiled himself
because he was unable to control his bowels. He also asked for housekeeping and they didnt come until he lodged a complaint with the doctor 2 days later.

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10 PHYSICAL EXAMINATION: General survey:
Height: 57 Weight: 240 lbs. BMI:37 (obese) should be under 24.9 Pain (rating, location): 0/10
Pulse: 60 Blood Pressure (location): 127/41 Left upper arm Temperature (route taken): Oral 97.7
Respirations: 18 BPM SpO2: 100% on room air BS: 230
Overall Appearance: Good condition. Clean, hair combed, dress appropriate for setting and temperature, maintains eye
contact, no obvious handicaps, except when standing or walking there was some difficulty.
Overall Behavior: Awake, calm, talkative, but somewhat anxious as he is ready for discharge.
Mood/Affect: Pleasant, cooperative, quiet unless asked a question. He wouldnt initiate conversation. At times anxious. Had
more of a flat affect and never really smiled. Occasionally would furrow his brow when talking about his hospital experiences.
He had a few moments where he looked like he was sad when he was talking about his children. Behavior was appropriate.
Speech: Clear, understandable, and able to speak full sentences without being winded. It occasionally would take a few
moments to find the right words to say.
Integumentary: Cap refill < 3 seconds. Skin pink, warm to the touch, and slightly diaphoretic. Spots of ecchymosis on
bilateral arms. Severe ecchymosis RT side chest, likely from CPR. Skin around pacemaker is warm, pink, and dry with no
hematoma and is non-tender. Overall skin is fragile. Skin turgor slightly tented. Hair and nails all normal quality with no
abnormalities.
IV Access: Double lumen PICC line Lt forearm inserted 11/4/15. The skin around it was dry, intact, no edema. No IV fluids
running. No peripheral IV devices.
HEENT: Facial features symmetric, no pain in sinus region, no pain or clicking of TMJ, trachea midline, thyroid not enlarged,
no palpable lymph nodes, Eyes PERRL 3mm, sclera white and conjunctiva clear without discharge, peripheral vision intact,
eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness, EOM intact through 6
cardinal fields without nystagmus, ears symmetric without lesions or discharge. Whisper test heard: 1 foot behind both ears,
nose without lesions or discharge, lips slightly dry, buccal mucosa, floor of mouth, & tongue pink & moist without lesions.
Dentition in good condition. No dentures.
Pulmonary/Thorax: Lungs clear upper, mild rhonchi lower lobes RT > LT lower. RR WNL, unlabored except when standing
or walking, equal chest rise and fall, NL posterior chest excursion. Tactile fremitus NL. Transverse to AP 2:1, no barrel chest or
chest deformities. Percussion resonant throughout upper lung fields and decreased in the lower fields, dull towards posterior
bases. Sputum production: NONE (thick thin scant small moderate large). Color: No sputum color to assess.
Cardiovascular: No lifts, heaves, or thrills. PMI felt at 5th intercostal mid-clavicular, distal pulses equal 2+, NL heart tones at
S1 S2, no murmurs, clicks, or adventitious heart sounds. Palpable carotid with no bruits. No JVD. Paced sinus rhythm. Apical
pulse 60, radial pulses 60. Cap refill < 3 seconds. Negative calf pain bilaterally. Skin warm, pink, and dry, including the
extremities except the hands are cool. 1+ edema BLE.
GI: NL bowel sounds heard all 4 quadrants, no bruits. Abdomen protuberant and non-tender, soft, and no masses felt. No
organomegaly, percussion dull over liver and spleen and tympanic over stomach and intestines. Bedside commode for bowel
movements. Bathroom privileges with assistance. CVA punch without rebound tenderness. Last BM: 11/10/15, semi-formed,
light brown, no hematochezia coffee grounds or tar appearance. Hemoccult: not performed
GU: Foley indwelling catheter. Urine output: clear, yellow, no sediment. Urine output: 1,050ml. Patient reports genitalia is
clean, moist, without discharge, lesions, or odor. No external exam performed.
Musculoskeletal: NL active ROM without assistance without crepitus. Slight overall weakness, rating: 4 against some
resistance all extremities. (0-absent, 1-trace, 2-not against gravity, 3-against gravity but not resistance, 4-against some resistance, 5-against full resistance). No
atrophy or wasting. No kyphosis, lordosis, or scoliosis. Pulse motor sensory x 4. No pain pallor paralysis, parathesias.
Neurological: Awake, A&O x 4 and answering questions appropriately. No confusion. CN 2-12 grossly intact. Sensation
decreased all toes bilateral feet due to neuropathy. Rombergs negative. Stereognosis, graphesthesia, and proprioception test
intact. Gait is slightly unbalanced and unable to walk without assistance. DTR Triceps, Biceps, Brachioradial, Patellar,
Achilles: 1+ (rating: o-absent, 1+ sluggish/diminished, 2+ active/expected, 3+ hyperactive, 4+ hyperactive with intermittent or transient clonus). Ankle clonus:
Negative. Babinski: Negative.
Other: Bandaging around pacemaker LT upper chest, clean dry and intact.

University of South Florida College of Nursing Revision August 2013 10

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent NL as well as abnormal, include
rationale and analysis. List dates with all labs and diagnostic tests and why they were performed):
Labs / Tests
ECG
Troponin: 4.59 HH, BNP: 22,158 H,
BUN: 88 H, Creatinine: 3.5 H, GFR: 17
L, PaCo2: 54 HH, HCO3: 14.6 LL,
Lactate: 8.7 HH, Na+: 133 L, K+: 5.9 H
Chest X-Ray
Chest X-Ray
CPK: 366 H, ALT: 186 H, AST: 153 H,
Na+: 137 NL, K+: 4.0 NL, PaCo2: 25
NL, BUN: 77 H, Creatinine: 4.0 H,
GFR: 19 L, INR: 1.25H
Na+: 144 NL, K+: 4.5 NL, Lactate: 1.8
NL
ECG
PaCo2: 39 NL, HCO3: 25.9 NL, pH:
7.43 NL
BNP: 33,076 H, Na+: 138 NL, K+: 4.0
NL, BUN: 56: H, Creatinine: 3.5 H,
GFR: 18
Dates Trend Analysis
10/27/15 N/A V-tach, no previous ECG for
comparison.
10/27/15 N/A Results indicate that significant changes
in blood chemistries and hematologic
parameters occur during and after
cardiac arrest and spontaneous
resuscitation. Some of these findings
also likely related to comorbidities such
as CHF and CKD. Also NL BNP is
high due to worsening HF after arrest.
Expected findings.
10/27/15 @ 15:08 N/A Prominent cardiac silhouette to be
expected after cardiac damage due to
HTN, CHF, MI, and cardiac arrest.
10/27/15 @ 16:52 Symptoms worsening. 1st X-ray showed Pulmonary edema pattern with
no pulmonary edema. pulmonary vascular congestion and mild
X-ray also shows proper placement of bilateral alveolar opacities. Due to
ET tube. patients CHF, instability of their
condition due to cardiac arrest and
spontaneous resuscitation.
10/28/15 Worsening liver and renal function Expected findings post cardiac arrest
and recovery.
10/30/15 Labs are normalizing as the patient is Expected finding as the patient is
treated with O2, medications, fluids, etc. healing and recovering.
11/02/15 Sinus Rhythm, PVCs, prolonged PR Improved from initial ECG. This is
interval, and Lt BBB expected as the patient is recovering.
11/02/15 Continuing to trend downward and Improved from prior labs. This is
improving. expected as the patient is recovering.
11/6/15 With the exception of the BNP While renal labs are still high, they are
worsening, all other labs continuing to lower than they were prior. It does
trend downward. appear as though HF is worsening, but
expected to an ejection fraction rate of
less than 35% after cardiac arrest.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

(Diet, vitals, activity, scheduled diagnostic tests, consults, Accucheck, etc. Also provide rationale and frequency if applicable.)
Continue on the cardiac monitor to monitor for arrhythmias
Monitor vitals every 4 hours to assess for changes.
Continue assessing for signs of infection and changes in mentation.
Continue with meds treating chronic conditions.
Renal Diet due to CKD this is an appropriate diet. Encourage him to eat > 50%.
Continue getting PT INR, due to Warfarin.
Continue with Accucheck prior to every meal to assess for BS >100.
Fall precautions; continue with yellow armband and socks, bed alarm, and calling for assistance as needed.
Encourage to change positions at least every 2 hours and get up regularly to sit in the chair.
Moisture management PRN.

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

1. Decreased cardiac output r/t post MI, cardiac arrest, CHF, and e/b decreased ejection fraction
2. Activity intolerance r/t CHF, decreased cardiac output, post-surgical recovery, and e/b exertional discomfort.
3. Readiness for enhanced knowledge: expresses an interest in learning, changing diet, going to rehab, and making f/u
doctor appointments and e/b asking for ways to change their life more positively.

University of South Florida College of Nursing Revision August 2013 11

 15 CARE PLAN Nursing Diagnosis:
Patient Goals/Outcomes
Demonstrate adequate CO as evidenced
by BP, pulse rate, and rhythm WNL;
maintain NL level of mentation, lack of
chest discomfort or dyspnea. An ability to
tolerate activity without symptoms of
dyspnea, syncope, or chest pain. (HR <
100, SBP > 90 but < 120, temperature <
100.5, SAO2 > 92%, urine output over
30mL per hour. HCT over 30)
Long term goal: The patients HR will
maintain a NL sinus rhythm on oral meds.
The patient will participate in prescribed
physical activity with appropriate changes
in heart rate, blood pressure, and
breathing rate: Patient will verbalize an
understanding of the need to gradually
increase activity based on testing,
tolerance, and symptoms and will
verbalize any discomfort. Patient will
demonstrate increased tolerance to
activity. Long term: the patient will have
increased strength and will be able to
tolerate walking short distances without
becoming dyspneic or experiencing
fatigue and/or pain.
The patient will meet personal health-
related goals, explain how to incorporate
new health regimen into lifestyle, list
sources to obtain information, and
actively participate in improving their
health and strength. Long term: patient
will no longer have to think about how to
make his life healthier, but rather it will
become a way of life. Patient will make
all follow-up appointments and will have
successfully completed rehab.
(Listed in order of importance. Which nursing diagnosis you are doing on your care plan on goes here.)
Nursing Interventions to Achieve
Goal
Recognize primary characteristics of
decreased CO. Continue to monitor the
patients heart rhythm and adjust
medications as needed to control the rate
and rhythm. Monitor and report presence
and degree of symptoms. Administer O2
as needed, monitor pulse ox, have the
patient maintain an activity level that
doesnt compromise CO. Closely
monitor fluid intake. Apply graduated
compression stockings.
When getting the patient up, observe for
symptoms of intolerance. Monitor and
record the patients ability to tolerate
activity, noting the HR, BP, rhythm, use
of accessory muscles, dyspnea,
diaphoresis, both during and after the
activity. Instruct the patient to stop
activity immediate and report symptoms
if they are experiencing any discomfort.
Include the patient as a member of the
health care team in mutual goal setting
when providing education. Use
motivational strategies to promote client
participation and sustain learning.
University of South Florida College of Nursing Revision August 2013
Rationale for Interventions
Provide References
EB: A nursing study to validate
characteristics of the nursing diagnosis
decreased cardiac output in a clinical
environment identified and categorized
related client characteristics that were
present as primary and secondary.
(Martins, Alita, & Rabelo, 2010).
EB: Exercise-based cardiac rehabilitation
is effective in reducing total and
cardiovascular mortality and hospital
admissions. (Du et al, 2009). Symptoms
of intolerance to activity and continuation
of activity may result in client harm
(Urden, Stacy, & Lough, 2010; Goldman,
2011.)
EB: Involving individuals in setting goals
that are relevant and meaningful to them
is an important component of supporting
client participation (Davis & White,
2008). The use of motivational and
disease management interventions has
demonstrated promise for improved
adherence and lifestyle change (Dusing,
2008).
Evaluation of Goal on Day of Care
is Provided
The patient had normal cardiac output as
evidenced by vitals and mentation. BP,
HR was both within NL limits.
The patient was able to stand and take a
few steps on his own. He remained pain
free, but was unable to tolerate standing
or walking for more than a minute or two.
Outside of his RR, the rest of his vitals
remained WNL, including SPO2 while
remaining on room air. The patient also
reported when he was experiencing
discomfort.
The patient met their goal by getting up
and attempting to walk around. He
verbally expressed the desire to become
healthier and making an active effort to
improving his lifestyle.
12
 DISCHARGE PLANNING: (Put a * in front of any patient education in above care plan that you would include for discharge teaching)
Social Services Consult: None
Dietary Consult: Discuss healthier eating options and how to reduce NA+ and protein. Have patient consult a dietitian to customize a diet for his co-
morbidities.
PT/ OT: May need after rehab, depending on weakness and activity.
Pastoral Care: Has no religious needs.
Durable Medical Needs: Patient already has TED hose and a walker at home.
F/U appointments: F/U with patients cardiologist and PCP. Contact Heart Specialists of Sarasota to schedule f/u apt in 7-10 days for a would threshold check.
Med Instruction/Prescription: No new medications being added
Are any of the patients medications available at a discount pharmacy? Insurance covers sending away for 3 month prescriptions. All of the prescriptions
are available as generics and can be found at Wal-Mart. Can sign up for a free program app on cellphone for GoodRX. It offers discount coupons and price
compares all prescriptions at all local pharmacies.
Rehab/ HH: Going to cardiac rehab
Palliative Care: While in hospital, provide comfort measures and give medications according to MAR for pain. Administer O2 for decreased SAO2.
Other: No vigorous activity with your implant arm to including lifting the arm over head for one month. Lift no more than 10lbs with the implant arm for one
month. No driving for one week or as discussed with your physician.

University of South Florida College of Nursing Revision August 2013 13

 References

Ackley, B., & Ladwig, G., (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.).

Maryland Heights, MO: Mosby.

ChooseMyPlate.gov. (2011). Retrieved July 14, 2015, from http://www.choosemyplate.gov/

Osborn, K.S., Wraa, C. E., Watson, A.B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for practice (2nd

ed., p. 927). Upper Saddle River, NJ: Pearson.

Unbound Medicine, Inc. (2015). Daviss drug guide (Version 1.17) [Mobile application software]. Retrieved from

https://itunes.apple.com/us/app/daviss-drug-guide-updates/id301427093?mt=8

University of South Florida College of Nursing Revision August 2013 14