UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Stacy Dunham

PATIENT ASSESSMENT TOOL . Assignment Date: 02/19/16

1 PATIENT INFORMATION Agency: SMH

Patient Initials: JF Age:69 Admission Date: 02/18/16

Gender: F Marital Status: Married Primary Medical Diagnosis with ICD-10 code:

Primary Language: English Dyspnea: R06.00

Level of Education: High School Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired from Accounting CHF - acute
Number/ages children/siblings: 2 children. 1 M: 40, 1 F: 43

Served/Veteran: Never Code Status: Full Code

Living Arrangements: Lives with his spouse. Her husband will take Advanced Directives: No
care of her. They live in a home with no step. If no, do they want to fill them out? No
Surgery: N/A
Culture/ Ethnicity /Nationality: American German / English

Religion: Protestant Type of Insurance: Medicare / Medicaid

1 CHIEF COMPLAINT:
Over the last few days I had increased difficulty breathing. When I began to experience chest tightness, I thought I should go to the hospital
because I had a heart attack in the past. She also had a dry cough and increased restlessness that she believed was related to her HTN
medication.

3 HISTORY OF PRESENT ILLNESS:

The patient was admitted in ER on 02/18/2016 for dyspnea, EKG showed left atrial enlargement and borderline T wave elevation. BNP was
positive for severe heart failure, > 900. The patient was treated with Lasix and Nitro with relief of dyspnea, anxiety, and tightness in chest.
Patient reporting only mild symptoms at this time. The plan is to discharge the patient to home with no needs.

Onset: Current:
O: Slowly O: Slowly
L: Chest L: Chest
D: Over 2 days D: decreased over the last 24 hours
C: anxiety / n chest C: mild dyspnea
A: on exertion A: on exertion
R: sitting R: sitting
T: None T: Lasix, Nitro
S: 10/10 S: 4/10

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date Operation or Illness
1960 DMI Humalog / Lantus
1995 CAD / Hyperlipidemia Crestor / heart healthy diet
1995 HTN amlodipine / metoprolol /
1995 Diabetic neuropathy - gabapentin
2006 GERD - omeprazole
2/2008 MI heart cath / stent / clopidogrel / ASA
2008 Depression bupropion / temazepam
2/2016 date CHF Nitro / furosemide / hydralazine Patients home meds indicate she was on hydralazine and furosemide prior
questionable due to to admission. Patient was unaware she had CHF and thought this medication was just for HTN and fluid retention
home meds not related to heart failure.
1950s Appendectomy
1980 Total hysterectomy
2006 Left breast mastectomy Breast CA
12/2015 AV fistula right forearm CRF

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
of
Cancer

Tumor
Stroke
Gout
Death

Father D MI X X X
Mother D CVA X X X X X X
Brother 71 X X
Aunt 84 X X X
Comments, and include date of onset:
She believes her Aunt and mother had an early onset of DMI around the ages of 15-20. Father had onset of cardiac problems in his 40s.
Brother had onset of HTN in 40s. She wasnt sure about the rest.

1 IMMUNIZATION HISTORY
(May state U for unknown, except YES NO
Routine childhood
for Tetanus, vaccinations
Flu, and Pna) X Approx 1950s
Vaccinations for military or federal service X
Adult Diphtheria (Date) UNK
Adult Tetanus (Date) X Approx 2012
Influenza (flu) (Date) X Refused
Pneumococcal (pneumonia) (Date) X Refused
Vaccines for intl travel or occupational purposes? X

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 1 ALLERGIES OR ADVERSE REACTIONS
NAME Type of Reaction (describe explicitly)
Medications: Demerol GI distress
Percocet GI distress
Hydralazine Dizziness and disorientation
Other (food, tape, latex, dye,
NONE
etc.)

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.
Heart Failure: Heart failure is where the heart is weaker than normal and is no longer functioning at full capacity and is
unable to keep up with the bodys demands. As the heart weakens pressure in the heart increases, which in turn causes the
heart to become congested and it impairs circulation causing pulmonary and peripheral edema impairing gas exchange within
the body. In addition, since the heart is no longer able to pump out as much blood to the body, it can activate the RAAS
system causing a release of enzymes causing further fluid retention. Heart failure is due to either systolic failure or diastolic
failure. Systolic failure is where the heart can no longer eject blood with as much force as it once use to, and diastolic failure
is due to the left ventricles inability to relax and fill with enough blood to provide to the body. Heart failure is divided into
two types, right and left-sided. Left-sided failure presents with symptoms of pulmonary edema, which can present as shortness
of breath, worsening of dyspnea when sleeping, orthopnea dyspnea when lying flat, dizziness, chronic cough which may have
pink frothy sputum associated with it, anxiety, worsening symptoms with exertion, lethargy, and rales. Right-sided failure
presents with dyspnea, anxiety, edema in the limbs, ascites, JVD, decreased appetite, nausea and vomiting. There are four
classes associated with this disease. In the first the patient is asymptomatic. The second the patient will have some mild
symptoms, such as shortness of breath with some activity. In the third the patient will have an increased amount of symptoms,
and in the fourth the patient will have symptoms all the time. Risk factors for this disease are: CAD, MI causing death of a
portion of the heart, uncontrolled hypertension causing hypertrophy, electrolyte imbalances, hyperlipidemia due to a poor diet
or genetic factors, obesity, diabetes, cardiomyopathy, aortic stenosis, alcohol consumption, and cigarette smoking. Genetic
factors should also be considered by assessing the patients family history for CAD, diabetes, hypertension, etc. There are
many tests which can be performed to test for and or look for signs of heart failure. A B-natriuretic peptide (BNP) lab value
will be drawn, as this is only secreted by the ventricles when they have been stretched or damaged, indicating heart failure and
the severity. A chest X-ray may be performed to look for heart enlargement. An EKG is a standard test to look for
hypertrophy, ischemia, arrhythmias, or conduction delays. An echocardiogram will measure the hearts ejection fraction rate
and will tell whether the person is suffering from diastolic or systolic dysfunction, as well as identify valve diseases.
Treatment will include lifestyle modification including a change in diet, limiting sodium, exercise, limiting alcohol, and
cessation of smoking. Medications to treat heart failure may include loop or potassium-sparing diuretics, beta blockers, ACE
inhibitors, ARBs, calcium channel blockers, vasodilators, or antiarrhythmics. Other therapies or even surgery are options as
well, including dialysis, cardiac pacemakers and/or defibrillators, a ventricular assist device, and as a last resort a heart
transplant. Prognosis for this disease will vary dependent on the severity of the disease, compliancy of the patient with
treatment, the overall health of the patient, and other contributing risk factors. Despite advances in heart failure treatments,
the mortality rate from heart failure remains high. Nearly 290,000 people die annually of heart failure in the United States
(Osborn, Wraa, Watson, Holleran, 2010).

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: Aspirin (acetylsalicylic acid) Concentration: 325mg 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. Patient Teaching: 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.

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Name: Lopressor (metoprolol) Concentration: 100mg Dosage Amount: 1tablet
Route: oral Frequency: twice daily
Pharmaceutical class: beta blocker Both
Indication: HTN
Side effects: bradycardia, HF, pulmonary edema, 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.
Patient Teaching: 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: Plavix (clopidogrel) Concentration: 75mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: platelet aggregation
Both
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. Patient Teaching:
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: Norvasc (amlodipine) Concentration: 5mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: calcium channel blocker Both
Indication: HTN
Side effects: bradycardia, dizziness, fatigue, peripheral edema, angina, hypotension, palpitations, gingival hyperplasia, nausea, flushing.
Nursing considerations: Take apical pulse before administering and do not give if HR below 50. Patient Teaching: 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: Crestor (rosuvastatin) Concentration: 10 mg Dosage Amount: 1 tablet

Route: oral Frequency: once daily at bedtime
Pharmaceutical class: lipid-lowering agent Home
Indication: hyperlipidemia
Side effects: amnesia, confusion, dizziness, h/a, insomnia, memory loss, weakness, rhinitis, bronchitis, chest pain, edema, abdominal cramps,
constipation, flatus, heartburn, altered taste, drug induced hepatitis, dyspepsia, increased liver enzymes, nausea, pancreatitis, erectile
dysfunction, rash, pruritus, hyperglycemia, arthralgia, arthritis, immune-mediated necrotizing myopathy, myalgia, myositis, hypersensitivity
Adverse: rhabdomyolysis. Nursing considerations: LFTs should be monitored regularly on this patient. Monitor of for symptoms of liver
damage, such as jaundice and hyperbilirubinemia. Discontinue usage if the patient develops these. If the patient develops muscle tenderness,
then monitor CK levels. Also monitor for proteinuria and hematuria. Patient Teaching: Take the medication as directed and do not skip a
dose. If miss a dose, take as soon as possible, but do not double dose. If they are to take antacids, they need to take this medication at least 2
hours later. Restrict fats from diet, and they should exercise and quit smoking. This medication doesnt cure hyperlipidemia, and should still
lead a healthier diet. Females should notify physician prior to getting pregnant, as this is pregnancy category X. They should notify their
physician immediately if they begin having muscle pain, tenderness, weakness, and fever, as this could indicate a life threatening problem.
Report any other side effects / adverse reactions. They should use caution when operating machinery, as it can cause dizziness and confusion.
They should limit alcohol and increase water and fiber in their diet as it can cause constipation. They should have follow-up labs regularly.
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Name: BiDil (hydralazine/isosorbide) Concentration: 60mg ER Dosage Amount:1 tablet
Route: oral Frequency: once in the morning
Pharmaceutical class: vasodilator / nitrates Home
Indication: HTN and CHF
Side effects: dizziness, drowsiness, h/a, angina, tachycardia, arrhythmia, edema, orthostatic hypotension, sodium retention, myalgia, N/V/D,
hypotension, apprehension, abdominal pain, cross-tolerance, flushing. Nursing considerations: Monitor BP and pulse. Take apical pulse
before administering and do not give if HR below 50. Monitor CBC, and serum electrolytes. Assess for signs of peripheral neuritis. Patient
Teaching: 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: Lasix (furosemide) Concentration: 40mg Dosage Amount:1 tablet

Route: oral Frequency: once daily
Pharmaceutical class: loop diuretic Both
Indication: CHF / HTN / Renal disease
Side effects: blurred vision, dizziness, h/a, tinnitus, hearing loss, hypotension, N/V/D, increased liver enzymes, constipation, and pancreatitis,
increased BUN, increased urination, hypercholesterolemia, hyperglycemia, hyperuricemia, metabolic alkalosis, thrombocytopenia, muscle
cramps. Adverse effects: Erythema multiforme, SJS, toxic epidermal necrolysis, aplastic anemia, agranulocytosis. Nursing considerations:
Monitor I&O, and daily weight. Monitor for signs of hypotension and dehydration. Monitor BP and pulse before and during administration.
Assess for signs of tinnitus and/or hearing loss with administration. Dilute and administer slowly, as well as check for y-site incompatibility.
Assess for allergies to sulfonamides and for skin rash. Patient Teaching: Instruct the patient to take the medication as directed. Advise of side
effects. Emphasize importance of follow-up exams. Advise to change positions slowly to reduce changes of orthostatic hypotension. Advise
their physician if they have a weight gain of more than 3lbs in 1day. 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. Advise the patient to follow a low sodium diet,
exercise regularly, and quit smoking. 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.

Name: Humalog (insulin lispro) Concentration: 100 units/mL Dosage Amount: sliding scale 35-45 units
Route: SQ Frequency: three times daily
Pharmaceutical class: pancreatics Home
Indication: DMI
Side effects: hypokalemia, lipodystrophy, pruritus, erythema, swelling. Adverse effects: anaphylaxis, hypoglycemia. Nursing
considerations: Assess BS prior to administration. Assess for signs of hypoglycemia after administration and monitor body weight
periodically. Monitor BS regularly and an A1C should be performed every 3-6 months. Monitor serum K+. Patient Teaching: Instruct on
proper administration technique. Inform on signs and symptoms of hypoglycemia. Advise the patient to take as directed and dont double if
they miss a dose. Advise of compliancy and risks associated with hyperglycemia. Have them advise their physician if BS remains
uncontrolled. Have them follow a glycemic diet and have them exercise regularly.

Name: Prilosec (omeprazole) Concentration: 20mg Dosage Amount: 1 capsule

Route: oral Frequency: once daily
Pharmaceutical class: proton pump inhibitor Both
Indication: GERD
Side effects: Dizziness, drowsiness, fatigue, h/a, weakness, constipation, flatulence, itching, rash, B12 deficiency, Psuedomembranous colitis,
hyperglycemia, hypomagnesemia, bone fracture, abdominal pain, N/V/D. Adverse effects: C-diff associated diarrhea (CDAD). Nursing
considerations: Assess routinely for epigastric or abd pain, and for occult blood in stool, emesis, or gastric aspirate. Monitor for CDAD, CBC
with differential, and serum Mg+. May need to obtain AST, ALT as it can cause abnormal liver function. Patient Teaching: Instruct the
patient to take the medication as directed. Advise of side effects. Advise to avoid alcohol and products containing NSAIDS. Advise the
patient to report any signs of bleeding, dark tarry stools, diarrhea, abdominal pain or persistent h/a. Emphasize importance of f/u exams.

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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? Consistent Carbohydrate (185g Co-morbidities/cultural considerations: CAD, CHF, HTN, DMI, CKD, GERD
CHO divided into 3 meals daily).
24 HR average home diet: calories
Diet patient follows at home? Consistent Carbohydrate
Protein
Grains Vegetables Fruits Dairy
Foods
Breakfast: 1 banana, 2 slices of wheat toast
Lunch: 1/2 sandwich on wheat. Usually eats 4 oz. turkey or Target 6 oz. 2 cup(s) 3 cup(s) 3 cup(s) 5 oz.
tuna, 1 tomato slice, lettuce, and mustard, low fat yogurt. Eaten 3 oz. 1 cup(s) 1 cup(s) 1 cup(s) 6 oz.
Dinner: 4 oz. chicken in a salad with low fat Italian dressing
Snacks: occasionally an apple or 1 serving whole wheat Status Under Under Under Under Over
crackers Allowance: 2000 calories Eaten: 954 Remaining: 1046
Liquids (include alcohol): approx. 48 oz. of water, 12 oz. cup Oils limit: 6 tsp., Eaten: 0 tsp.
black coffee. Sat Fat limit: 22 g, Eaten: 9g
Sodium limit: 2300mg, Eaten: 2391mg , Fiber: 3mg
(ChooseMyPlate.gov. 2011)

NOTE: She is not consuming enough calories.
Recommendation: Good nutrition is of high importance in those who have several health
risk factors. However, eating the right kinds of food while undergoing treatment and after
can contribute to better health and increased strength. A poor diet will contribute to
increased lethargy, weakness, and slow healing, while a well-rounded diet will contribute
to better health, increased strength, and healing. Her decreased appetite is likely due to
lethargy and worsening health related to CHF and associated dyspnea. A healthier diet
where she consumes more calories and balances intake of all food groups will likely
improve her overall health. She should also decrease the amount of sodium she is
consuming due to HTN and CHF, and increase the number of carbs and vegetables she
consumes. She should also decrease the amount of protein she is consuming due to CKD.

1 COPING ASSESSMENT/SUPPORT SYSTEM

Who helps you when you are ill? Her husband Joe.
How do you generally cope with stress, or what do you do when you are upset? She stated she suffers from depression o/o
and will often cry. She also seeks comfort from her spouse.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)? Yes. Her
biggest worry is for her 7 y/o granddaughter who has cardiac issues and is having surgery next month. She states she is my
world. She states her own chronic health issues are also a source of stress and depression, as well as not being as active as she
once use to be.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? Yes
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 be in the Ego Integrity stage
and is appreciative of the life she has lived, her family, and is accepting the end of her life is likely near. She is focusing more
on family than herself, I believe because she realizes at this juncture her future of her health is already set in place. She is also
focusing more on family because she isnt certain how much longer she will have. She appears a little anxious, at times
depressed, but is very pleasant and approachable.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life: She
states she knows overall her health isnt good, but it isnt because she doesnt lead a healthy lifestyle. She states her family
history has played a big part in the severity of her health.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?: She states she knows it all started with diabetes and how it has deteriorated
her entire body.
What does your illness mean to you? She states, it scares me. When asked why, she stated she wants to be around to see
her granddaughter grow up.

+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Men
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? Not that shes aware of.
Have you or your partner received the Gardasil (HPV) vaccination? She asked, what is it? No.
Are you currently sexually active? No, I just dont have the energy anymore.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? No
How long have you been with your current partner? 45 years
Have any medical or surgical conditions changed your ability to have sexual activity? Im sure all of it did, but it got
worse after I had my heart attack.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
You have to have sex for that.

1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life? She states she prays more often than she used to but more
often it is for others. She states it does lighten her mood.
Do your religious beliefs influence your current condition? Yes, having faith in a higher power takes the weight off of me.

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

1) Smoking:
Does the patient currently, or has he/she ever smoked or used chewing tobacco? No
If so, what? N/A
How much? N/A
For how many years? N/A
(age: 15 thru: 55)
Pack Years: N/A

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If applicable, when did the patient quit? N/A
Does anyone in the patients household smoke tobacco? No
Has the patient ever tried to quit? N/A

2) Alcohol:

Does the patient drink alcohol or has he/she ever drunk alcohol? Not anymore, but she use to

What? Red wine How much? 8 oz. Frequency? Once a month. For how many years? 38 years (age: 20 thru: 58 )
If applicable, when did the patient quit? Around 2005-2006 when she began experiencing GERD more frequently

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? N/A

10 REVIEW OF SYSTEMS
Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
X Changes in appearance of skin -
X GERD Cholecystitis Fever
DRYNESS
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 - doesnt go in sun
Diverticulitis Life threatening allergic reaction
SPF:
Bathing routine: daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
X Last colonoscopy? APPROX 2006
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary X Anemia
X Cataracts or Glaucoma X nocturia ONCE NIGHTLY Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: 8+ TIMES Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
X Routine brushing of teeth twice daily X Diabetes Type: I
X Routine dentist visits EVERY 5 YRS Hypothyroid /Hyperthyroid
X Vision screening - ANNUALLY Intolerance to hot or cold
Other: Osteoporosis
Other: HYPERPARATHYROID
Pulmonary
X Difficulty Breathing 2/18/16 Central Nervous System
X Cough ONGOING DRY COUGH WOMEN ONLY CVA

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 Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam: NO Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? 10+ YEARS Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
X last CXR? 2/18/16 menopause age? Meningitis
Date of last Mammogram &Result: 1 YR -
Other: Other:
NEGATIVE
Date of DEXA Bone Density/Result: N/A
Cardiovascular MEN ONLY Mental Illness
X Hypertension Infection of male genitalia/prostate? X Depression
X Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? XAnxiety
X Myocardial Infarction 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 X Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
X Last EKG screening, when? 2/18/16
X Arthritis X Chicken Pox
LEFT ATRIAL ENLARGEMENT
Other: Other: LEFT FOOT DROP Other:

General Constitution
Recent weight loss or gain: NO
How many lbs? N/A
Time frame? N/A
Intentional? N/A
How do you view your overall health? POOR

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? No. Patient states she has never been told she
has CHF before and she is confused. She states she saw her cardiologist 12/2015 and all tests were negative.

Any other questions or comments that your patient would like you to know? She wanted to know the acute CHF was related to her heart or her kidneys.

10 PHYSICAL EXAMINATION: General survey:

Height: 64in Weight: 62.8kg BMI: 23.77 borderline, but WNL Pain (rating, location): 4/10 for dyspnea, no pain
Pulse: 84 Blood Pressure (location): 148/86 Left upper arm Temperature (route taken): 98.1 Oral
Respirations: 20 BPM SpO2: 100% 2L O2 BS:192
Overall Appearance: Good condition. Clean, hair combed, dress appropriate for setting and temperature, no obvious
handicaps.
Overall Behavior: Alert with verbal. She is friendly and willing to talk, but is a bit restless and anxious.
Mood/Affect: Pleasant, cooperative, and willing to talk. Affect sad at times, other times smiling.
Speech: Clear, understandable, and able to speak full sentences with slight difficulty.
Integumentary: Cap refill < 3 seconds. Skin pink, warm to the touch, and dry. All over skin dryness, and skin turgor slightly
tenting. Hair and nails all normal quality with no abnormalities.
IV Access: None
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, unable to perform EOM
or Whisper test as the patient couldnt stay awake long enough. The nose without lesions or discharge, lips slightly dry, buccal
mucosa, floor of mouth, & tongue pink & moist without lesions. Dentition her own and in good condition for her age.

University of South Florida College of Nursing Revision August 2013 9

Pulmonary/Thorax: RR somewhat labored and shallow. RUQ: clear, RMQ: diminished, RLQ: rales, LUQ: diminished, LLQ:
rales. Equal chest rise and fall. Dry cough. Transverse to AP 2:1, no barrel chest or chest deformities. Percussion dull
throughout. 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 x 4 equal 2+, Carotid: 3+,
Apical pulse: 3+. NL heart tones at S1 S2, no murmurs, clicks, or adventitious heart sounds. Palpable carotid with no bruits.
No JVD. NL sinus rhythm. Apical pulse 80, radial pulses between 60-100. Cap refill < 3 seconds.
GI: NL bowel sounds heard all 4 quadrants, no bruits. Abdomen slightly protuberant and non-tender, soft, and no masses felt.
No organomegaly, percussion dull over liver and spleen and tympanic over stomach and intestines. CVA punch without
rebound tenderness. Last BM: 2/18/16, NL in size and quality, soft, medium brown. Hemoccult: not performed. Didnt
observe genitalia.
GU: Did not view any output as patient voids on her own. The system noted the patient voids urine, yellow, and clear. Patient
reports genitalia is clean, dry, without discharge, lesions, or odor. No external exam performed.
Musculoskeletal: NL active ROM without assistance without crepitus. Overall strength: 5/5 x 3, 3/5 Left foot. (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. Parathesias left foot.
Neurological: Eyes PERRL. A&O x 4. CN 2-12 grossly intact. Sensation intact. Rombergs negative. Stereognosis,
graphesthesia, and proprioception test intact. Able to ambulate without assistance and steady. DTR Triceps, Biceps,
Brachioradial, Patellar, Achilles: 2+ (rating: o-absent, 1+ sluggish/diminished, 2+ active/expected, 3+ hyperactive, 4+ hyperactive with intermittent or transient
clonus). Ankle clonus: Negative. Babinski: Negative.
Other: N/A

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 Dates Trend Analysis
Chest PA/Lateral X-ray 02/18/2016 Nothing to compare it to at this time. Small left pleural effusion, left basilar
atelectasis, right lung clear. Expected
findings with pulmonary edema r/t
CHF.
U/S Renals 02/19/2016 Nothing to compare it to at this time. Echogenic kidneys, no hydronephrosis.
2cm midpole parapelvic cyst right
kidney. Urinary bladder is incompletely
distended. Normal findings for person
with CKD and age of patient.
ECG 02/19/2016 Compared to ECG on 2/18/2016, T NL sinus with left atrial enlargement
wave abnormality is no longer present. and borderline T wave elevation.
Trending downward and CHF related Expected findings for a patients age
symptoms are resolving due to and history.
treatment.
Echocardiogram and CT U/S 02/19/2016 Nothing to compare it to at this time. Pending results
BNP: 3753 H 02/18/2016 Nothing to compare it to at this time. BNP levels consistent with acute onset
BUN: 41 H CHF, Stage IV. BUN and Creatinine
Creatinine: 2.46 H levels consistent with someone who has
Troponin: negative renal failure, and may also have an
aspect of acute renal injury due to acute
CHF. Troponin indicates CHF not due
to recent MI.
Troponin: negative 02/19/2016 No change from prior lab run. Troponins again negative, adding
All other labs pending. further credence CHF was not due to
recent MI.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

(Diet, vitals, activity, scheduled diagnostic tests, consults, Accucheck, etc. Also provide rationale and frequency if applicable.)
Monitor vitals every 4 hours to assess for changes.
Monitor labs, follow BS, assessing for any decline.
Assess for decreased cardiac output regularly.
Continue assessing for signs of infection and changes in mentation related to infection and/or worsening respiratory
function.
Monitor I&O to assess and progress towards goals.
Assess skin integrity, edema, and provide moisture management PRN.
Continue with meds treating chronic conditions.

University of South Florida College of Nursing Revision August 2013 10

 Encourage the patient to eat > 50% of estimated caloric needs, continue with consistent carb diet.
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.
Provide K/Mag protocol as necessary
Maintain respiratory status. Continue on 2L and assess if there is a need to increase.
Continue with Lasix for pulmonary edema until symptoms resolve.
Repeat chest X-ray, BNP.
Review results as they come in for hemogram, Chem 8, echocardiogram and CT U/S
Contact physician if worsening symptoms.

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

1. Impaired gas exchange r/t extravascular fluid in lung tissues and alveoli, altered oxygen supply, and inability to
transport oxygen secondary to CHF e/b hypoxia, pulmonary edema, elevated BNP levels, and the need for
supplementary oxygen.
2. Excess fluid volume r/t cardiac dysfunction, CHF, and sodium and water retention e/b ventricular failure, pulmonary
edema, hypoxia, anxiety, and increased lethargy.
3. Activity intolerance r/t impaired respiratory function secondary to CHF e/b lethargy, hypoxia, and the need for
supplementary oxygen.
4. Deficient knowledge r/t the diagnosis of heart failure e/b patient stating she was never told she had heart failure before,
and she was unaware the medications she was on was directly related to treating heart failure.

University of South Florida College of Nursing Revision August 2013 11

 15 CARE PLAN Nursing Diagnosis:
Patient Goals/Outcomes
The patient will demonstrate improved
ventilation and adequate oxygenation as
evidenced by blood gas levels within normal
parameters. Maintain clear lung fields and
remain free of signs of respiratory distress.
Patients RR rate will remain between 10-20
BPM, depth, and ease of respiration will
remain WNL during this shift. Patient will be
able to tolerate activity and speak full
sentences. Patients mentation will remain
A&O x 4. Long Term: The patient will not
need supplementary O2 and her lungs will
remain free of pulmonary edema.
The patient will maintain clear lung fields and
remain free of signs of respiratory distress.
Patients hemodynamic parameters will
remain WNL. Patient will have at least 30mL
urinary output per hour. Patients weight will
remain appropriate, and/or have a weight gain
of less than 1lb per day. Serum sodium levels
will remain WNL. BNP levels will decrease to
acceptable levels.
(Listed in order of importance. Which nursing diagnosis you are doing on your care plan on goes here.)
Nursing Interventions to Achieve
Goal
Monitor patients vitals, including RR, depth,
and ease of respiration. Watch for use of
accessory muscles, nasal flaring cyanosis,
pallor and diaphoresis. Monitor for signs and
symptoms of worsening respiratory distress,
such as cyanosis, change in mentation, tripod
position, and pursing of lips.
Auscultate lung sounds to assess for presence
of fluid. Monitor SPO2 levels and keep > or =
to 94%. Monitor arterial blood gases.
Encourage the patient to deep breathe and
cough. Have patient continue on telemetry to
monitor for cardiac compromise.
Monitor for signs of worsening pulmonary
congestion. Assess for a patent airway, RR <
20 BPM, equal chest rise and fall, SPO2 >
94% with supplementary O2. Monitor
patients vitals, including RR, depth, and ease
of respiration. Watch for use of accessory
muscles, nasal flaring cyanosis, pallor and
diaphoresis. Keep head of bed elevated 30-
45%. Monitor I&O greater than 1,000 mL / 24
hours. Monitor daily weight, limit sodium
intake, and assess laboratory and diagnostic
studies are WNL. Monitor for tachycardia.
Provide sodium restricted diet. Monitor all lab
values for any abnormalities. Implement fluid
restriction as ordered. Monitor for side effects
of diuretics.
University of South Florida College of Nursing Revision August 2013
Rationale for Interventions
Provide References
EB: A study demonstrated when the RR > 30
BPM, along with other physiological
measures, a significant cardiovascular or
respiratory alteration exists (Hagle, 2008).
The presence of crackles and wheezes may
alert the nurse to airway obstruction, which
may lead to or exacerbate hypoxia. Central
cyanosis of the tongue and oral mucosa is
indicative of serious hypoxia and is a medical
emergency (Bickley & Szilagyi 2009).
EB: Heart failure results in dyspnea, edema,
orthopnea, and elevated central venous
pressure. The secondary characteristics are
weight gain, hepatomegaly, JVD, palpitations,
crackles, oliguria, coughing, clammy skin, and
skin color changes (Martins, Aliti, & Raelo,
2010). In a patient with fluid overload, an
increase in urine volume and dilution will
usually be observed (Jones, 2011).
Evaluation of Goal on Day of Care
is Provided
The patient was able to maintain SPO2
between 100% on 2L O2, and there was no
need to increase O2. The patient had normal
cardiac output as evidenced by BP, HR, and
rhythm remaining within NL limits. RR and
arterial blood gases remained WNL. The
patient did report mild anxiety and some
respiratory distress level 4/10. The patients
condition remained stable and there were no
signs of worsening symptoms.
Patients skin warm pink and dry, cap refill <
3 seconds, distal pulses 2+, equal, regular,
SPO2 100%, pending lab studies. There was
no need to administer any IV fluids as patient
is consuming enough fluids in her diet and
I&O sufficient. The patient had normal
cardiac output as evidenced by BP, HR, and
rhythm remaining within NL limits. RR and
arterial blood gases remained WNL. The
patient did report mild anxiety and some
respiratory distress level 4/10. The patients
condition remained stable and there were no
signs of worsening symptoms.
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 consuming more calories to improve overall health.
PT/ OT: N/A
Pastoral Care: Has no religious needs at this time.
Durable Medical Needs: Patient already has brace for foot drop.
F/U appointments: F/U with cardiologist.
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: None. Being discharged to home.
Palliative Care: While in hospital, provide comfort measures and give medications according to MAR for pain. Continue on O2 for decreased SAO2.
Other: N/A
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 March 13, 2016 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. 1026). Upper Saddle River, NJ: Pearson.

Treas, L., & Wilkinson, J., (2014). Basic Nursing: Concepts, Skills & Reasoning. Philadelphia, PA: F.A. Davis Company.

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

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