Final Pat

University of South Florida College of Nursing Revision May 2012 1
UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

2
CC: I have trouble breathing. The pain in my chest goes over my whole body.

+3 HPI: OLD CART The patient is a 66-year-old white female who complains of chest pain and difficulty
Breathing. Onset was one night ago. Location is chest and left shoulder, flank, upper extremity and lower back. Duration
Of pain is constant. Character is tightness, squeezing, and radiating. Aggravating factors include
Ambulation, lying flat, excessive talking. Relieving factors include rest, pain meds, oxygen. Pain varies in severity and
Acuteness.

Student: Deanne (Dee) Buchholtz
PATIENT ASSESSMENT TOOL
LONG FORM FUNDAMENTALS
Assignment Date: 11/11/12

Agency: SFB
Patient Initials: LP Age: 66 Admission Date: 10/12/12 (midnight)
Gender: F Martial Status: S Occupation: Retired
Primary Language: English

Level of Education: Some college
Number/ages children/siblings: 1 son, 48
2 daughters, 40 & 49

Primary Medical Dx with ICD-10 code: Acute chest pain
Code: 786.50
Living Arrangements: Lives with son Advanced Directive: Call full code
Immunizations: Does not know immune. Hx Code Status: Full code

Culture/ Ethnicity /Nationality: Caucasian

Surgery Date: None scheduled Procedure: NA

Religion: Christian

Type of Insurance: Medicare IP

2 PMH/PSH Hospitalizations for any medical illness or operation
Date Operation or Illness Management/Treatment
2002 Hip reduction Uses cane/walker
2004 Triple bypass Daily meds
2002-2012 3 catheterizations Pacemaker monitor
2005 Pacemaker inserted
2012 Stint

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Father 52 Kidney disease x x x x x x
Mother 87 Still living x x
Brother 52
Massive
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Sister
relationship

relationship

relationship

Comments:

1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations x
Routine adult vaccinations for military or federal service x
Adult Diphtheria (Date) x
Adult Tetanus (Date) x
Influenza (flu) (Date) NR
Pneumococcal (pneumonia) (Date) NR
Have you had any other vaccines given for international travel or
occupational purposes? Please List x


1 Allergies or
Adverse Reactions
NAME of
Causative Agent
Type of Reaction (describe explicitly)
Medications
Avandia Profuse emesis

Zoloft Rash

Other (food, tape,
dye, etc.)
Latex Rash
Plastic

5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis,
prognosis or treatment)
Acute chest pain, in this case, is r/t angina and Myocarditis. Angina is blockage in the heart blood vessels that reduces
blood flow and
Oxygen to the heart muscle itself, causing pain but not permanent damage to the heart. The chest pain may spread to your
Arm, shoulder, jaw, or back. It may feel like pressure or squeezing sensation. Can be triggered by exercise, excitement,
Or emotional distress and is relieved by stress.
Myocarditis is the inflammation of the muscle and may cause fever, fatigue, and trouble breathing. Although no blockage
Is associated with myocarditis, symptoms resemble those of a heart attack. (WebMD)

5 MEDICATIONS: (Include both prescription and OTC)
Name Niacin Concentration NA Dosage Amount 1,000 mg
Route PO Frequency 2x daily
Pharmaceutical class precursor of NAD; water soluble B vitamin
Home Hospital or Both Hospital
Indication lowers cholesterol
Side effects/Nursing considerations For diabetics, monitor changes in blood sugar levels

Name omega 3 Concentration NA Dosage Amount 1,000 mg
Route tablet PO Frequency 3x daily
Pharmaceutical class ethylester
Indication reduce triglycerides
Side effects/Nursing considerations upset stomach, loose stools, nausea

Name Protonix Concentration NA Dosage Amount 40 mg
Pharmaceutical class Proton pump inhibitor
Indication treatment of NSAID-related ulcers
Side effects/Nursing considerations headache, diarrhea, vomiting, abd pain
Name ascorbic acid Concentration NA Dosage Amount 500 mg
Pharmaceutical class collagen formation and tissue repair
Indication prevent vascular thrombosis
Side effects/Nursing considerations burning, itching

Name Apirin Concentration NA Dosage Amount 81 mg
Pharmaceutical class NSAID
Indication antithrombolitic
Side effects/Nursing considerations ulcers, bleeding risk

Name Metoprolol Concentration NA Dosage Amount 50 mg
Route tablet Frequency 2x daily
Pharmaceutical class Beta blocker
Indication hypertension
Side effects/Nursing considerations hypotension, bradychardia

Name Insulin Concentration NA Dosage Amount low dose SS
Route subQ Frequency 4x daily
Pharmaceutical class naturally occurring hormone
Home Hospital or Both Both
Indication DM
Side effects/Nursing considerations hypoglycemia

Name Lipitor Concentration NA Dosage Amount 10 mg
Pharmaceutical class Atorvastatin calcium
Indication lower cholesterol
Side effects/Nursing considerations cough, difficulty swallowing, fast heartbeat

Name Plavix Concentration NA Dosage Amount 75 mg
Pharmaceutical class Inhibitor of ADP-induced platelet agg.
Home Hospital or Both
Indication Reduce/prevent atherosclerotic events
Side effects/Nursing considerations bleeding risk

Name Heparin Concentration 5,000 units/mL Dosage Amount 1 mL
Route IV Frequency duration 999 dose
Pharmaceutical class parenteral anticoagulant
Indication HTN
Side effects/Nursing considerations hypotension, bleeding risk

Name Concentration Dosage Amount
Route Frequency
Pharmaceutical class
Home Hospital or Both
Indication
Side effects/Nursing considerations

4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Cardiac Analysis of home diet (Compare to food pyramid and
Consider co-morbidities and cultural considerations):
Diet pt follows at home? Diet appears generally balanced in protein and
carbohydrates. Intake of fruits and vegetables should be
increased.
Breakfast: Banana, oatmeal, coffee

Lunch: Veggie burger, iced tea, sometimes soda

Dinner: Chicken sandwich, iced tea

Snacks: Jello

2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Son

How do you generally cope with stress? or What do you do when you are upset? Take a walk, write/journal, prayer

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) Anxiety, being
Overwhelmed with stress from constant pain

+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?___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?
Are you currently in a safe relationship? No

5 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 XEgo Integrity vs. Despair
Give the textbook definition of both parts of Ericksons developmental stage for your patients age group:
Ego Integrity vs. Despair- Asks the question Is it ok to have been me? As we grow older, we tend to slow down our
Productivity and explore life as a retired person. We contemplate our accomplishments and whether we led a successful
Life. If we dont view ourselves as productive, we develop despair, leading to depression and feelings of hopelessness.
Describe the characteristics that the patient exhibits that led you to your determination:
Patient describes herself as depressed and lonely, despite living with her son. She denies making any positive
contributions to the world. She fears she wont live to see her grandchildren grow up

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Heart problems, due to the constant nature of pain, has increased feelings of frustration and despair.

+3Cultural Assessment:
What do you think is the cause of your illness?
Heredity and not eating right.

What does your illness mean to you?
Im not able to be active. I sit or lay all day.

+3 Sexuality Assessment: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of
life. All of these questions are confidential and protected in your medical record

Have you ever been sexually
active?______________NR______________________________________________________
Do you prefer women, men or both genders?
_____NR________________________________________________________
Are you aware of ever having a sexually transmitted
infection? ___NR____________________________________________
Have you or a partner ever had an abnormal pap
smear?_______NR______________________________________________ Have you or your partner received the
Gardasil (HPV) vaccination? ___________No________________________________

Are you currently sexually active? ______No_____________________When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? ______________NR____________________

How long have you been with your current
partner?______NA__________________________________________________

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 concerns

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much? For how many years?
(age thru )

If applicable, when did the
patient quit?

Does anyone in the patients household smoke tobacco? If
so, what, and how much? Father smoked in house
Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Wine, beer, liquor How much? 4-5 per week For how many years?
(age 20 thru 64 )

If applicable, when did the patient quit? 3 years ago

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

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

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No

REVIEW OF SYSTEMS (TO BE USED FOR DATA COLLECTI ON ONLY)
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 x 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: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia 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: Unknown
Post-nasal drip Normal frequency of urination: 4 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2 x/day Diabetes Type:
Routine dentist visits 0 x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
x Difficulty Breathing 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 NR Migraines
Pneumonia Date of last gyn exam? Unknown Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies xmenarche age? 14 Encephalitis
last CXR? 10/13/12 x menopause age? 50 Meningitis
Other: Date of last Mammogram &Result: NR Other:
Date of DEXA Bone Density & Result:NR
Cardiovascular MEN ONLY Mental Illness
xHypertension Infection of male genitalia/prostate? Depression
x Hyperlipidemia Frequency of prostate exam? Schizophrenia
xChest pain / Angina Date of last prostate exam? Anxiety
xMyocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
xMyocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
x Last EKG screening, when? 10/12/12 Arthritis Chicken Pox
Other: Other: Other:

University of South Florida College of Nursing Updated April 2012 10

+10 REVIEW OF SYSTEMS: (Include health promotion/maintenance activities)
General Overall Health Status: Patients overall health status is fair to poor, marked by complications of chest pain r/t
angina and myocarditis. Patient ambulates with difficulty and has trouble breathing, which impedes ADLs.

Integumentary: Patient denies having problems with nails, dandruff, psoriasis, hives, skin infections. Patient does not
Use sunscreen.

HEENT: Patient denies having problems with seeing, cataracts, glaucoma, hearing, infections, sinus pain, nose bleeds
post-nasal drip, oral/esophageal infections, dental problems. Patient brushes teeth twice daily.

Pulmonary: Patient claims difficulty breathing, but denies cough, asthma, bronchitis, emphysema, pneumonia, TB,
Environmental allergies. Last CXR 10/13/12. Management involves meds and limited ambulation.

Cardiovascular: Patient claims problems with HTN, hyperlipidemia, angina, MI, and myocarditis. Patient denies problems
With CAD/PVD, CHF, murmur, thrombus, rheumatic fever, and arrhythmia. Last EKG screening 10/12/12. Treatment
And management involves meds, frequent screenings and pacemaker, cardiac diet, limited ambulation.


10 REVIEW OF SYSTEMS: (continued)
GI: Patient claims problems with ulcers and treats them with antacids. Patient denies problems with nausea, vomiting,
Diarrhea, constipation, GERD, indigestion, hemorrhoids, jaundice, pancreatitis, colitis, diverticulitis, appendicitis,
abscess, IB, cholecystitis, bloody stools, or hepatitis.

GU: Patient denies problems with nocturia, dysuria, hematuria, polyuria, or kidney stones. Patient urinates 4-5 times
Daily.

Musculoskeletal: Patient denies any injuries or fractures, weakness, pain, gout, osteomyelitits, or arthritis.

Neurological:Patient denies problems with CVA, dizziness, severe headaches, migraines, seizures, ticks or tremors,
encephalitits, or meningitis.

Endocrine: Patient has DM type II, but denies problems with hypo/hyperthyroidism, intolerance to hot/cold, or
osteoporosis

Hematologic: Patient denies problems with anemia, bleeds, bruises, or cancer. The patient denies having any blood
transfusions. Blood type is unknown.


PHYSICAL EXAMINATION(TO BE USED FOR DATA COLLECTION ONLY)
Orientation and level of Consciousness: oriented x3 and LOC x4
General Survey: Height: 55 Weight: 180 BMI: 30 Pain: (include rating & location)
(6) Chest, lower back, bilateral
Upper/lower extremities
Pulse: 72 Blood
Pressure: R arm 140/90
(include location)
Temperature: (route taken?) Respirations: 14
SpO
2 97
Is the patient on Room Air or O
2
: 2L NC
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X 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]
X awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
X clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative x quiet boisterous flat
apathetic bizarre agitated anxious tearful x withdrawn aggressive hostile loud
Other:
Integumentary
X Skin is warm, dry, and intact
X Skin turgor elastic
X No rashes, lesions, or deformities
X Nails without clubbing
X Capillary refill < 3 seconds
X Hair evenly distributed, clean, without vermin

X Peripheral IV site Type: .5 NS Location: L hand Date inserted: 10/12/12
X no redness, edema, or discharge
Fluids infusing? no x yes - what? Heparin
Peripheral IV site Type: Location: Date inserted:
no redness, edema, or discharge
Fluids infusing? no x yes - what?
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?

HEENT: x Facial features symmetric x No pain in sinus region x No pain, clicking of TMJ x Trachea midline
X Thyroid not enlarged x No palpable lymph nodes x sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
Functional vision: right eye - left eye - without corrective lenses right eye 20/20 left eye 20/20 x with corrective lenses
Functional vision both eyes together: x with corrective lenses or NA
X PERRLA pupil size /3 mm x Peripheral vision intact x EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge x Whisper test heard: right ear- 8 inches & left ear- 8 inches
X Weber test, heard equally both ears Rinne test, air 2 time(s) longer than bone
X Nose without lesions or discharge x Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Intact, white, with partial denture
Comments: None

Pulmonary/Thorax: Respirations regular and unlabored x Transverse to AP ratio 2:1 x Chest expansion symmetric

X Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
X Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
X Tactile fremitus bilaterally equal without overt vibration
CR - Crackles
Sputum production: thick thin Amount: scant small moderate large
RH Rhonchi
Color: white pale yellow yellow dark yellow green gray light tan brown red
D Diminished

S Stridor

Ab - Absent

Cardiovascular: x No lifts, heaves, or thrills PMI felt at: 5
th
ICS Midclavicular line
Heart sounds: S
1
S
2
Regular Irregular x No murmurs, clicks, or adventitious heart sounds x No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
X Calf pain bilaterally negative x Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid:3 Brachial: 3 Radial: 3 Femoral: 3 Popliteal: 2 DP: 2 PT: 2
X No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: bilateral upper/lower extremities pitting non-pitting
X Extremities warm with capillary refill less than 3 seconds

GI/GU: x Bowel sounds active x 4 quadrants; no bruits auscultated x No organomegaly Liver span 7 cm
X Percussion dull over liver and spleen and tympanic over stomach and intestine x Abdomen non-tender to palpation
Urine output: x Clear Cloudy Color: light yellow Previous 24 hour output: 525 mLs N/A
Foley Catheter Urinal or Bedpan x Bathroom Privileges without assistance or with assistance
X CVA punch without rebound tenderness
Last BM: (date 10 / 13 / 12 ) 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
Genitalia: Clean, moist, without discharge, lesions or odor x Not assessed, patient alert, oriented, denies problems
Other Describe:

Musculoskeletal: x Full ROM intact in all extremities without crepitus
X Strength bilaterally equal at _3_ in UE & _3_ in LE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
X vertebral column without kyphosis or scoliosis
X 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

+10 PHYSICAL EXAMINATION:
Orientation and level of Consciousness: Oriented x3 LOC x4
General Survey: Height: 55 Weight:180 BMI: 30 Pain: Chest, lower back,
Blood
Pressure: 140/90
Bilateral upper/lower
Temperature: 97.8 oral Pulse: 72 extremities
(route taken?) Respirations 14 SpO
2 97
On Room Air or O
2
: 2L NC
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
Makes eye contact, dress appropriate for the season, general cleanliness

Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
Appears lethargic and subdued, but responds appropriately to questions

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
Speech is clear

Mood and Affect: [e.g.: appropriate/apathetic/bizarre/agitated/other]
Mood is subdued and depressed, but polite to questions
Integumentary
Overall skin is intact, warm, dry and without lesions,
Bruising, or bleeding. Skin turgor is elastic. No nail
Clubbing and capillary refill is less than 3 seconds.
Hair is evenly distributed and is clean and free of
Vermin.

HEENT: Facial features are symmetric, no pain in the sinus region, no clicking of TMJ. Trachea is midline, thyroid not
Enlarged, and lymph nodes are non-palpable. Sclera is white and conjunctiva is clear without discharge. Eyebrows, lids,
Orbital area, lashes, and lacrimal glands are symmetric without edema or tenderness. R and L eyes are 20/20 with
Corrective lenses. Pupils are 3mm, peripheral vision is intact, with EOM intact through 6 cardinal fields with no nyst-
Agmus. Ears are symmetric without lesions or discharge. Whisper test heard in both ears at 6 inches. Weber test heard
Equally in both ears and Rinne test, with air conduction twice as great as bone conduction. Nose is without lesions or
discharge. Lips, mucosa, floor of mouth and tongue are pink and moist without lesions. Dentition is intact. Patient has
Partial denture.

Pulmonary: Respirations are labored with wheezing. Transverse to AP ration is 2:1, with symmetrical chest expansion.
Lungs clear to auscultation in all fields, percussion is resonant in all fields and dull towards bases. Tactile fremitus
Is bilaterally equal without overt vibration. No sputum production.

Cardiovascular: No heaves, lifts, or thrills. PMI felt at 5
th
ICS midclavicular line. Heart sounds S1 and S2 regular. No
Murmurs, clicks or adventitious heart sounds. No JVD. Calf pain bilaterally negative, pulses a 3 at apical, carotid,
Brachial, radial, femoral, and a 2 at popliteal, DP, and PT. No temporal or carotid bruit. +1 Edema at upper/ lower
Extremitites, with no pitting. Extremities are warm with cap refill under 3 seconds.

GI: Bowel sounds active at 4 quadrants, no bruit auscultated. No organomegaly. Liver span is 7 cm. Percussion is dull
Over liver and spleen and tympanic over stomach and intestine. Abdomen is nontender to palpation.

GU: Urine output is clear and light yellow. Output is 525 mL over 24-hrs. No catheter or bedpan. Uses bathroom
CVA punch without Out tenderness. Last BM date is 10/13/12, formed, dark brown, with no hemocult. Genitalia not
Assessed.

Musculoskeletal:Full range of motion in all extremities without crepitus. Strenght bilaterally equal at 3 in UE and LE.
Vertebral column without kyphosis or scoliosis. Neurovascular status intact: peripheral pulses palpable, no pain,
Pallor, paralysis or paresthesias


PHYSICAL EXAMINATION: (continued)

Neurological: Not assessed

+10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS: (include rationale and analysis)
EKG performed, revealed atrial fibrillation

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
Patient admitted to PCU and placed on heart monitor. Patient placed on cardiac diet.


2 Medical Diagnoses
(as listed on the chart)
8 Nursing Diagnoses
(actual and potential - listed in order of priority)
1.Acute chest pain r/t unstable angina and atrial 1.Failure to thrive r/t unstable angina evidenced by
fibrillation Acute chest pain and

2. Hypertension 2. At risk for falls r/t bilateral lower extremity edema
And weakness

3. 3. Ineffective breathing pattern r/t acute chest pain
Evidenced by wheezing

4. 4. At risk for inadequate nutritional status r/t complications
Of type II DM

5. 5.

15 for Care Plan
Nursing Diagnosis:
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for Interventions
Provide References
Evaluation of Interventions
on Day care is Provided
Will understand importance of Pamphlet on cardiac diet and Proper nutrition is a crucial part of Patient understands need to
Managing DM and cardiac issues Low-sugar diet for DM; sample Treatment and management of Monitor diet and maintain
With diet meals Chronic health issues, such as DM Appropriate diet, restricting
And HTN. Foods high in sugar, sat. fats, and
Sodium.

No falls this shift Patient will ambulate with walker These steps help ensure patient Falls prevented this shift
Or nurse assistance to use toilet Is not left alone or out of reach of
And bathe. Call light within reach. Medical assistance.
Bed alarm on. Side rails up.

Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)

Consider the following needs:
SS Consult
X Dietary Consult
PT/ OT
Pastoral Care
X Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

Nursing Diagnosis:
Achieve Goal
Provide References


SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Rehab/ HH
Palliative Care

Nursing Diagnosis:
Achieve Goal
Provide References

SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Rehab/ HH
Palliative Care

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University of South Florida College of Nursing Revision May 2012 1

UNIVERSITY OF SOUTH FLORIDA

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