UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Narjess Yazback

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 2/12/14

Agency: BMC

Patient Initials: Y.T.

Age: 76 years old

Admission Date: 2/7/14

Gender:

Marital Status: Widow

Primary Medical Diagnosis with ICD-10 code:

Heart failure- I50.9

Female

Primary Language: English

Level of Education: High school/ special courses

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Private business owner (Promotional

products)
Number/ages children/siblings: 1 Son (deceased in 1976-drowning
accident)-was 21 years old
Served/Veteran: No

Code Status: Full code

Living Arrangements: Lives in a 55+ community with a roommate,

on the first floor.

Advanced Directives: Living will

If no, do they want to fill them out?
Surgery Date: 2/14/14
Procedure:
Mitral/tricuspid valve replacement

Culture/ Ethnicity /Nationality: Caucasian

Religion: Christian Methodist

Type of Insurance: Humana Gold Plus

1 CHIEF COMPLAINT:
Patient states that the reason they sought help is because I was having a very hard time catching my breath, and I am so
swollen, I keep gaining weight.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 76 year old female who was referred to Doctor J.P. by her primary care physician for admission from the
emergency room. Patient presented to the emergency room on 2/7/ 14 complaining of shortness of breath. She explains
that it has been going on for several weeks and gets worse week after week. She says that nothing seems to relieve the
feeling and that her surgery being postponed is making her very anxious. The patient had a mitral and tricuspid valve
replacement about 5 years ago. She initially did well, but had recurrent atrial fibrillation. Patient was recently reevaluated, and found to have severe mitral stenosis and moderate pulmonary hypertension. The last cardiac catheterization
which showed these results was done in December 2013 at Largo Medical. This woman was scheduled to have surgery
today 2/7/14 at Largo Medical Center, but surgery was cancelled because of some scheduling/ equipment issues with the
surgeon. She was then referred to a surgeon at BMC by her physician. An EKG, Chest X-ray and labs were drawn in the
ER and she was placed on a 2L nasal canula. This woman also underwent a CT scan of the thorax on 2/7/14, and the
results were: large pleural effusion, and extensive amount of Ascites. Patient was then transferred to the cardiac floor at
BMC. On 2/10/14 a transesophageal Echocardiogram of the patient showed moderate mitral regurgitation and stenosis,
mild to moderate aortic stenosis, tricuspid valve regurgitation, and a left atrial appendage thrombus was noted. Patient is

University of South Florida College of Nursing Revision August 2013

scheduled for a mitral/ tricuspid valve replacement on 2/14/14 with Doctor J.P.

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

Operation or Illness
Hypertension (Managed with diet and exercise)
Appendectomy

2000, 2008
2004
2009

Hysterectomy (No specific date given, patient states it was in her early 30s)
Total knee replacement surgery
DDD pacemaker for sick sinus syndrome
Open heart surgery with mitral valve replacement and tricuspid valve replacement. (Has been on
Coumadin since then, this was stopped in December for catheterization. Patient is now on Lovanox)

Father

72

Mother

79

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)
Lung
cancer
Stroke

Environmental
Allergies

Diabetes Type II (no onset date provided)managed with nutrition and exercise + patient states I
sometimes take Metformin 500 mg twice a day, but I dont like how it makes me feel. In the hospital
it is being managed with sliding scale regular insulin).
Arthritis (hands)
Atrial Fibrillation (no onset date provided)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Age (in years)

1998
2001

Brother
Sister

39

Cancer

relationship
relationship
relationship

Comments: Include date of onset

Father died of lung cancer. He had one lung removed and passed 2 years later at 72. (No onset date provided by patient)
Mother died from complications of a stroke. She had hypertension since she was in her 40s. No medical interventions, she just tried
to stay active and exercise once in a while.
Sister passed at age 39 of cancer. (Diagnosis was late)

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)

YES

University of South Florida College of Nursing Revision August 2013

NO
2

Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus ( 20 years ago)
Influenza (flu) (Fall 2013)
Pneumococcal (pneumonia) (September 2013)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

Medications

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Heart failure is the inability of the heart to pump blood at the required rate for the perfusion of vital organs and body
tissues, or the ability to do so with an increased diastolic pressure. Cardiac output of blood is based on Heart rate and
stroke volume which encompasses preload, after load and contractility. In heart failure, preload (stretching and filling of
the heart) and after load (systolic pressure) are increased due to various risk factors observed below; and contractility is
decreased causing the ventricles to work harder. In some cases, contractility is increased to a point where the filling of
blood in the heart is vastly reduced, and blood flow is diminished. The RAA (Renin angiotensin aldesterone) system also
contributes by causing vasoconstriction which obstructs the blood flow, increases absorption of sodium and water in the
body and results in hypertension. This is the number one risk factor of heart failure. (Dumitru, 2013). Chronic
Hypertension is a major risk factor of heart failure because it can lead to hypertrophy of the heart and atherosclerosis
which weaken the pumps abilities therefore increasing the hearts workload (Huether &McCance, 2012, p.589). Other
risk factors include Diabetes mellitus which causes damage to the bodys blood vessels, obesity, Coronary artery disease
(CAD) which blocks blood flow (vasoconstriction) due to plaque buildup, myocarditis (Inflammation and infection),
congenital heart disease, arrhythmias, valve defects, excessive water and salt intake which increase blood pressure in the
body, recreational drugs (alcohol, cocaine), and medications with cardiac side effects (Huether & McCance, p.622).
There are a few different ways to diagnose heart failure; one of them is by testing the brain natriuretic peptide
(BNP) levels in the blood. If the levels are above 100pg/ml, it indicates the presence of heart failure. Depending on how
high the levels are, it can be rated from mild to severe. In this particular Patient, the BNP level was 719 pg/ml. Extra heart
sounds such as an S3 gallop can usually be heard in patients with heart failure, but this should not be used as the only
decisive diagnostic method. To determine which side of the heart is affected, observe for the following signs and
symptoms. In left-sided heart failure, pulmonary edema can occur, the patient manifests with orthopnea, cyanosis, fatigue,
tachycardia, and crackles are usually heard during auscultation. In right-sided heart failure, nausea, vomiting, and right
sided abdominal pain occurs due to liver congestion with blood. This leads to ascites and weight gain in the patient.
Constipation is also often seen in heart failure, and indicates decreased perfusion of blood to abdominal area. In elderly
patients the first signs and symptoms of heart failure can be fatigue and confusion. Other possible signs and symptoms of
diagnosis include tachycardia, chest pain and palpitations, distension of neck veins, and cyanosis. As part of the diagnosis,
patient should also be assessed for a complete cardiac history. (Dumitru,2013)

University of South Florida College of Nursing Revision August 2013

Heart failure can be stabilized by using treatments such as vasodilators (to dilate blood vessels and facilitate blood
flow), diuretics to decrease blood pressure and edema if present, and as a first line treatment to manage hypertension,
anticoagulants, digoxin, ACE inhibitors which decrease blood pressure by preventing vasoconstriction, and beta blockers
which reduce heart rate and the workload of the heart by blocking adrenaline from attaching to beta receptors. Other more
invasive therapies are also available in extreme cases of heart failure such as pacemakers and implantable cardioverterdefibrillators. Depending on how severe the heart failure is, non-pharmalogical therapies such as dietary sodium and fluid
restriction, lifestyle changes, physical activity as appropriate for patient and attention to weight gain are also available.
The mortality rate for heart failure patients after hospitalization is 22% after 1 year, and increases to 42.3 % at 5 years. If
patient is hypotensive, mortality rate are as high as 80%. Factors that could impact treatment and prognosis include
noncompliance with dietary revision/ lifestyle changes, and inadequate intake or discontinuing of prescribed medication
(Dumitru, 2013).

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

Concentration (mg/ml)

Route PO

Dosage Amount 25 (mg)

Frequency Daily

Pharmaceutical class: Potassium sparring diuretics

Home

Hospital

or

BothX

Indication: Management of edema associated with heart failure, cirrhosis. Management of essential hypertension.
Side effects: Hyperkalemia, GI irritation, dizziness, headache, arrhythmias, hair growth in females, SJS
Nursing considerations: check potassium levels, use with ACE inhibitors can increase risk of hyperkelemia. Monitor Intake and output ratios and daily weight.
Evaluate BP before administration. Signs of hyperkelemia are cardiac arrhythmias, fatigue, confusion, weakness, Paresthesia. Patients with diabetes are at
increased risks for these symptoms. Assess patient for skin rash. Labs: Monitor potassium labs, may decrease sodium levels, and monitor BUN, serum
creatinine. Discontinue 3 days prior to a glucose tolerance test because of risk of hyperkelemia. Administer w/ food or milk to avoid GI irritation.

Name: Lovenox

Concentration: 80mg/0.8 ml

Route: SQ

Dosage Amount: 80 mg

Frequency: Q12

Pharmaceutical class: antithrombotic: low molecular weight heparins

Home

Hospital

or

Both

Indication: Used for prevention of venous thromboembolism and pulmonary hypertension.

Side effects: bleeding, anemia, hyperkelemia, edema, constipation, erythema at injection site.
Nursing considerations: Monitor for hematoma and other anticoagulant drug to drug interactions. Assess for fall in hematocrit levels or BP, occult stool.
Monitor CBC and platelet count for labs. Teach patient to not rub site of injection.
** will be held on 2/13/14 prior to surgery on 2/14/14
Name: Potassium chloride

Concentration:

Route: PO

Dosage Amount: 1 Tab (20 MEQ)

Frequency: BID

Pharmaceutical class: mineral and electrolyte replacement

Home

Hospital

or

Both

Indication: treatment and prevention of potassium depletion.

Side effects: Arrhythmias, ECG changes, confusion, abdominal pain, diarrhea, flatulence, nausea, vomiting
Nursing considerations: monitor Potassium labs because patient is also on a potassium sparring diuretics. Use cautiously in diabetic patients and cardiac disease
patients. Monitor magnesium levels, monitor renal functions. Signs and symptoms of toxicity include slow irregular heartbeat, fatigue, muscle weakness, peaked
T-waves, depressed ST segments, and widened QRS complexes. Administer with or after meals to decrease GI irritation. Assess for dark, tarry or bloody stool.
Name: Aspirin

Concentration

Dosage Amount: 81 mg (1 tab)

Route: PO

Frequency: Daily

Pharmaceutical class: Salicylates

Home

Hospital

or

Both

Indication: For inflammatory diseases like arthritis and as a prophylaxis of transient ischemic attacks and MI.
Side effects: GI bleeding, nausea and vomiting, abdominal pain, tinnitus, anaphylaxis and laryngeal edema.
Nursing considerations: May increase risk of bleeding in patients on anticoagulants. Ginger and garlic may increase anticoagulant effects. Monitor hepatic
functions and check for increase in labs such as serum AST and ALT. Monitor hematocrit levels to assess for GI blood loss. Check platelet levels. Assess for
toxicity: onset of tinnitus, headache, hyperventilation, mental confusion, lethargy, diarrhea and sweating.
Name: Insulin (regular)

Concentration

Dosage Amount: Sliding scale (check blood

sugar)

University of South Florida College of Nursing Revision August 2013

Route: SQ

Frequency: AC/ HS

Pharmaceutical class: pancreatics

Home

Hospital

or

Both

Indication: For control of hyperglycemia for patient with type I or II diabetes

Side effects: Hypoglycemia, allergic reactions, swelling
Nursing considerations: Beta blockers may mask the signs of hypoglycemia. Salicylates may decrease insulin requirements. Assess for signs of hypoglycemia
such as anxiety, restlessness, tingling in hands and feet, chills, cold sweats, confusion, tachycardia and weakness. Monitor body weight (this may necessitate
changes in insulin dose). Ensure that the next meal is on the floor prior to administration of insulin dose.
Name: Bumex (bumetanide)

Concentration: 0.25mg/ ml

Route: IV push

Dosage Amount: 1mg

Frequency: Q12

Pharmaceutical class: loop diuretics

Home

Hospital

or

Both

Indication: for fluid overload due to heart failure

Side effects: Stevens Johnson Syndrome, toxic epidermal necrolysis, hearing loss, hypotension, dehydration, hypokalemia, hypomagnesemia, Hyponatremia,
hypovolemia, metabolic alkalosis.
Nursing considerations: Check labs for electrolytes levels (sodium, potassium, magnesium) because it can cause electrolyte depletion. Monitor liver enzymes,
daily weight, intake and output ratios. Assess skin Turgor and lung sounds. Monitor BP and pulse before and during administration. Assess for tinnitus and
hearing loss. Implement fall prevention strategies for patient on diuretics.
Name: Coreg (carvedilol)

Concentration

Dosage Amount: 12.5 mg (1tab)

Route: PO

Frequency: BID

Pharmaceutical class: Beta blocker

Home

Hospital

or

Both

Indication: For Hypertension and heart failure therapy with diurectis

Side effects: dizziness, fatigue, weakness, Bradycardia, HF, pulmonary edema, diarrhea, SJS, toxic epidermal necrolysis, bronchospasm, wheezing,
hyperglycemia.
Nursing considerations: Use cautiously in hepatic impaired patients. Symptoms of hypoglycemia may be masked in patients with DM. Monitor BP and pulse
during therapy. Assess for orthostatic hypotension. Monitor intake and output ratios and daily weight. Assess patient for fluid overload (Peripheral edema,
weight gain, JVD, crackles). Monitor blood glucose levels. Do not discontinue abruptly, may cause rebound tachycardia. Notify provider if bradycardia, severe
dizziness and dyspnea occur).
Name: Magnesium oxide

Concentration

Dosage Amount: 400 mg (1 tab)

Route: PO

Frequency: BID

Pharmaceutical class: electrolyte replacement supplement

Home

Hospital

or

Both

Indication: treatment and prevention of hypomagnesemia

Side effects: diarrhea, flushing, sweating
Nursing considerations: assess magnesium levels and renal function before administration. Give with a full glass of water. Do not take this medication w/ in two
hours of other medications.
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Cardiac diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular healthy
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1Banana, cup of oatmeal and 1mug coffee
(8ounces)
Lunch: Fruits (1 apple, mixed lettuce w/ tomatoes,
cucumbers,1 can tuna, balsamic vinaigrette )

Dinner: Steak and 1 cup mixed veggies

As seen above patients diet does not surpass the limit of

2000 calories a day, but their intake of empty calories
(soda, beer) is above the limit of 258. Being a heart failure
patient, fluid intake should be watched as well as sodium
intake. Raised sodium levels increases fluid retention in
the body. In this case the patient is below her limit of
sodium intake (2300 mg), but it should still be reduced.
Patient is also maintaining a good level of saturated fats by
staying under the limit of 22 g a day. Patient has a good
intake of vegetables and whole fruits, but should increase
intake of whole grains and dairy products. Patients
consumption of protein exceeds the limits of 5 ounces a day
with a consumption of 11 ounces a day. This should be
reduced by cutting down on daily meats.

Snacks: Dole fruit cup

Liquids (include alcohol): Diet soda (1 can at lunch),
Coffee at breakfast, about 3 bottles of water a day, 1 Beer
every night.

University of South Florida College of Nursing Revision August 2013

Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My house mate Marge.
How do you generally cope with stress? Or What do you do when you are upset? By keeping busy and Marge helps me
cope as well
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No except this anxiety I have been feeling with this doctor who kept cancelling and postponing my surgery, this is why I
am now here, I found another surgeon with Bayfront.
+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? _______No________ Have you ever been hit punched or slapped? ______________
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? I am a Widow.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:

In the Ego Integrity stage, older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads
to feelings of wisdom, while failure results in regret, bitterness, and despair (McLeod, 2008).

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

The patient has retired, but she is now running her own business, she mentions that she is the main promotional source for
her community, and that they need her. She feels good that she is still contributing and is able to help people. Patient does

University of South Florida College of Nursing Revision August 2013

not feel regretful of life, she is able to look back and communicate memories she has and she explained that it gives her a
sense of fulfillment to help her community and contribute.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

It did not really have a huge impact on her stage of life, it might have brought her mood down but she is not in a state of
despair, she has a lot of hope.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I have no idea; I have a long history of illnesses.
What does your illness mean to you?
I dont know, I am sick that is all I know.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes with my
husband.__________________________________________________________________
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?
_________No____________________________________________ 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? None with my husband, but I have
had a hysterectomy.
How long have you been with your current partner? Since I was 18, now I am 76, but he passed when I was 68.
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

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
It is very important.
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? Yes I have lots of people who love me and lots of prayers for me. (Patient
started tearing up).
______________________________________________________________________________________________________
______________________________________________________________________________________________________

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? House mate Marge smokes but
never inside the house. She always goes outside. Smokes a
pack a day.

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? (give specific volume)

For how many years?

(age 40

thru

76

1 beer a night
If applicable, when did the patient quit?
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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Not that I know of. I live in a safe neighborhood

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen no
SPF:
Bathing routine: Daily
Other:

HEENT
Difficulty seeing (has reading glasses)
Cataracts or Glaucoma
Difficulty hearing

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis (Date not provided)
Abdominal Abscess
Last colonoscopy? (November 2013)
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily ( On Coumadin since
2008)
Cancer
Blood Transfusions
Blood type if known: OOther:

nocturia
dysuria

Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

hematuria
polyuria (Pt on diuretics)
kidney stones
Normal frequency of urination: 7/8
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2
x/day
1 x/year

Diabetes
Type: II
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing Shortness of
breath
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? (Pt had
hysterectomy in her 30s)
menstrual cycle was regular
irregular

Environmental allergies
last CXR? 2/7/2014 at BMC
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF (has a pacemaker)
Murmur
Thrombus Left atrial
Rheumatic Fever
Myocarditis

Menarche
age? 14
Menopause
age?
Date of last Mammogram &Result:
Unknown
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout

Childhood Diseases
Measles
Mumps
Polio

University of South Florida College of Nursing Revision August 2013

10

Arrhythmias (Atrial Fibrillation)

Last EKG screening, when? 2/7/14
BMC
Other: Open heart surgery and Valve
replacement in 2009

Osteomyelitis

Scarlet Fever

Arthritis (Hands)

Chicken Pox

Other: had knee replacement one in 2000

and the other in 2008.

Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None
Any other questions or comments that your patient would like you to know?
None

University of South Florida College of Nursing Revision August 2013

11

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

General Survey: Patient is an Height: 53
Weight:175.6 Ibs
BMI:
Pain: 2 general
older female; she is awake, in Pulse: 76
Blood
bed and appears in no distress.
Pressure: 103/55 brachial
(include location)
Temperature: 98.2 oral
Respirations: 19
SpO2: 94%
Is the patient on Room Air or O2: 2L nasal canula
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact (Bruising of abdomen from
patient rubbing after Lovanox injections)
Skin turgor elastic
No rashes, lesions, or deformities (Enlarged abdomen
due to Ascites)
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

Peripheral IV site Type: 22 G

Location: R FA
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Fluids infusing?
no
yes - what?

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

IV
Incision for prior valve replacement

Date inserted: (2-09-14)

Date inserted:
Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3 / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 5 inches & left ear- 5 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: No dentitions present
Comments:

University of South Florida College of Nursing Revision August 2013

12

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Crackles present in left lower lobe, all other lobes sound clear with no
adventitious sounds.
Respirations are regular and unlabored with 2L nasal canula on.

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: Not assessed.
Heart sounds: S1 S2 present Regular Irregular (S3 sound auscultated)
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial: 2+
Radial: 2+
Femoral:
Popliteal:
DP:
No temporal or carotid bruits
Edema: LE
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

PT:

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: light yellow
Previous 24 hour output: mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 2 / 12 / 14 ) Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ____4___ RUE __4_____ LUE ___4____ RLE

& _4______ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
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 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):

Lab
Hemoglobin (Normal
12.1- 15.1 gm/dL)
L 11.7
L 11.7
L 9.9

RBC count (Normal 4.25.4 million cells/Mcl)

L 3.94
L 3.92
L 3.37

Dates
2/7/14
2/11/14
2/12/14

2/7/14
2/11/14
2/12/14

Trend
The hemoglobin levels
have been trending down
for the patient.

Patients red blood cell

count has been
consistently decreasing.

Analysis
Hemoglobin is a protein
in red blood cells that
carries oxygen. Low
hemoglobin may be
indicative of anemia,
destruction of RBC,
malnutrition and vitamin
deficiencies. This leads to
less oxygen perfusion in
the patients tissues.
Patient is on 2 L nasal
canula. Patients RBC has
been decreasing which
negatively affects the
hemoglobin levels in the
body.
This determines how
many red blood cells a
patient has. Red blood
cells contain hemoglobin
which carries oxygen,
therefore a low red blood
cell count can decrease
how much oxygen the
body receives. A low
RBC count can be caused
by bleeding,

BNP (Normal <100)

H 719.0

2/7/14

Patients BNP level is

elevated upon admission.

Troponin levels (Normal

0-0.1 ug/l)
0.01
0.01

2/7/14 11:20AM
2/7/14 17:27 PM

Patients Troponin levels

have remained the same.

Potassium (Normal 3.55.5 mEq/L)

3.8
4.0
4.7

Sodium (Normal 135-145

mEq/L)

2/7/14
2/11/14
2/12/14

2/7/14
2/11/14

Patients potassium levels

have been consistently
increasing.

Patients levels have an

upward trend. She came
in with low sodium, but it

erythropoietin deficiency
secondary to kidney
disease, anemia, and
malnutrition. Note that
patient is on an
anticoagulant which
could increase the risk of
bleeding.
BNP (brain natriutetic
peptide) is a protein made
by the heart. Levels are
higher than normal in
cases of heart failure
because it is secreted in
response to excessive
stretching of the heart
muscle.
Troponin is a protein that
is released when the heart
has been damaged (MI).
If a patient has had a
heart attack, troponin
levels will be above
normal within 6 hours. In
this case the patient has
not sustained any damage
to the heart tissue because
levels are normal.
Potassium is an
electrolyte in the body.
Potassium (K+) helps
nerves and muscles
communicate. It also
helps move nutrients into
cells and waste products
out of cells. This patient
is on a potassium sparring
diuretic and on a
potassium supplement,
and potassium levels are
consistently increasing, so
the nurse must monitor
labs to avoid
hyperkelemia.
Hyperkelemia can result
in cardiac dysrhythmias
and arrest.
Sodium is an electrolyte
that the body needs to
work properly. Low

L131
L134
137

BUN (Normal 6-20

mg/dL)
18
H25
H26

Creatinine (normal 0.61.1 mg/dL for women)

1.0
1.1
1.2

AST (Normal 10-34

IU/L)
25
22

2/12/14

2/7/14
2/11/14
2/12/14

2/7/14
2/11/14
2/12/14

2/7/14
2/11/14

is now within normal

ranges.

Patients levels have been

increasing, and they are
above normal levels.

Patients creatinine levels

have a positive trend as
they are increasing since
admission. However
levels remain within
normal ranges.

Patients levels have been

decreasing, but they
remain within normal
ranges.

sodium could be caused

by high fluid intake and
use of diuretics which is
the case of this patient.
They have been placed on
a fluid restriction.
BUN stands for blood
urea nitrogen. Urea
nitrogen is what forms
when protein is broken
down. These levels check
for kidney function.
Higher than normal levels
of urea nitrogen in the
blood is seen in patients
with congestive heart
failure, heart attack,
hypovolemia, kidney
disease, Bleeding in GI
tract, and excessive
protein levels in GI. In
this case the patient may
have an increase BUN
because they are
dehydrated. Patient is on
a fluid restriction, and she
is taking Bumex and
Aldactone which are
diuretics.
This test is used to
determine efficiency of
kidney functions.
Patients levels are within
normal ranges, but since
they are consistently
increasing, nurse should
monitor for kidney
problems that could be
due to reduced blood flow
to the kidneys, kidney
failure or infection and
dehydration. Intake and
output levels should also
be monitored along with
color of urine.
AST (aspirate
aminotransferase) is an
enzyme found in liver,
heart and muscle cells.
This test is usually done

TEE (Transesophageal
Echocardiogram)

2/10/14

Interpretation: moderate
mitral stenosis and
regurgitation was noted,
mild to moderate aortic
valve stenosis was
shown, moderate
tricuspid regurgitation,
and a left atrial
appendage thrombus
were displayed.

to monitor and diagnose

liver disease. High levels
can be due to cirrhosis of
the liver, low perfusion to
the liver, hepatotoxicity
medications, and low
levels may be due to
surgery, seizures, burns or
heart procedures. In this
patients case, the levels
are normal.
This test is done to look
for problems of the heart
such as heart valve
malfunctions, enlarged
heart, infections, blood
clots, stenosis of the
valves. In this patient
several problems were
found as described in the
trend section. The
procedure requires an
ultrasound probe to be
passed down the throat
and into the esophagus,
and then sound waves are
used to make images of
the heart.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Patient is on a strict cardiac diet, they are on fluid restriction (64 ounces a day-1800ml), Q4 vitals, AC, HS Accu
checks, and they are on a tele monitor since they have dysrhythmias.

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

1. Impaired gas exchange r/t to fluid collection AEB shortness of breath, abnormal chest X-Ray, and peripheral edema.
2. Activity intolerance related to imbalance between oxygen supply/demand AEB dyspnea and presence of dysrhythmias.
3. Decreased cardiac output related to valvular stenosis and altered heart rate AEB presence of s3 sound , edema and a

pacemaker.
4. Fluid volume excess r/t decreased cardiac output and water retention AEB s3 heart sounds, weight gain and respiratory
distress
5. Ineffective tissue perfusion r/t to decreased cardiac output AEB edema and altered BP readings.
6. Risk for impaired skin integrity r/t edema, decreased physical mobility and decreased tissue perfusion.
7. Fatigue r/t to heart failure AEB generalized weakness.
8. Deficient knowledge regarding condition, treatment regimen, self care and discharge needs r/t lack of understanding of
cardiac disease AEB statements of concern and misconception.

 15 CARE PLAN
Nursing Diagnosis: (Impaired gas exchange r/t to fluid collection AEB shortness of breath and peripheral edema.) (Ackley & Ladwig, 2011)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
1) Patient will maintain adequate
1) Auscultate breath sounds Q4
1) Reveals presence of pulmonary
Patient had an SPO2 of 94 % and
gas exchange and oxygen
noting any crackles or wheezes.
congestion indicating need for
they were maintained on 2L nasal
saturation above 92% throughout
2) Weight patient daily.
further interventions.
canula. Patient was in no distress
shift.
3) Instruct/teach patient effective
2) Drastic weight gain in a few
and did not have shortness of
coughing and deep breathing
days can indicate how much fluid
breath unless she was disconnected
(Ackley & Ladwig, 2011).
retention is occurring.
from the oxygen and walked to the
3) clears airway and facilitates
bathroom. Short term goal was
4)
Encourage
frequent
position
oxygen
delivery
successful, and long term goal is
2) Patient will demonstrate
change for patient.
still in progress.
adequate ventilation and
5)
Monitor
pulse
oximetry
Q4,
and
4)
This
helps
prevent
Atelectasis
oxygenation of tissues by
serial ABGS with changes in
and pneumonia.
ABGs/oximetry within patients
status.
5) Hypoxemia can be severe during
normal ranges and free of
6) Administer supplemental oxygen pulmonary edema; any changes
symptoms of respiratory
as indicated.
should be noted.
distress
7) Maintain head of the bed
6) May correct or reduce tissue
elevated at 20-30 degrees/ semi
hypoxemia.
fowler position. Support arms with 7) Reduces oxygen consumption
pillows.
and demands and promotes
8) Administer medications
maximal lung inflation while
(diuretics, bronchodilators) as
patient is breathing.
indicated
8) Enhances gas exchange by
increasing oxygen delivery, reduces
pulmonary congestion.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs

F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output related to valvular stenosis and altered heart rate AEB presence of s3 sound, edema and a pacemaker. (Ackley &
Ladwig, 2011)

Patient Goals/Outcomes
1) Patient will report
decreased/absent episodes of
dyspnea on this shift.

2) Patient will display vital signs

within acceptable limits,
dysrhythmias absent or
controlled, and no symptoms of
failure (e.g., hemodynamic
parameters within acceptable
limits, urinary output adequate,
peripheral edema diminished.)

Nursing Interventions to Achieve

Goal
1) Assess for abnormal heart and
lung sounds, heart rate and rhythm,
and document dysrhythmias on
telemetry Q4.
2) Palpate peripheral pulses Q4.
3) Monitor BP Q4 and trend.
4) Inspect skin for pallor, Cyanosis.
5) Note for changes in LOC
6) Encourage rest, semi recumbent
position in bed or chair, and assist
the patient with physical care as
needed.
7) Provide a quiet environment for
the patient, explain nursing and
medical procedures, listen to
expressions of fear or anxiety and
help the patient avoid stress.
8) Provide a bedside commode so
it is closer to the patient and have
patient avoid straining during
defecation (Increases vasovagal
response), or holding breath during
position changes.
9) Administer supplemental oxygen
as indicated.
10) Administer medications as
indicated by physician orders:
diuretics, anticoagulants, and beta
blockers.

Rationale for Interventions

Provide References
1) Dysrhythmias are often
associated with HF along with
adventitious heart sounds. It is
important to note these.
2) Decreased cardiac output may
be reflected in diminished
peripheral pulses. Pulses may be
fleeting or irregular to palpation.
3) In early moderate or chronic HF
BP may be elevated at first, but in
advanced HF the body may no
longer be able to compensate and
the patient can be severely
Hypotensive.
4) Pallor occurs with decreased
perfusion secondary to reduced
cardiac output.
5) Changes in LOC may indicate
decreased cerebral perfusion due to
reduced cardiac output.
6) Physical rest should be
maintained to improve efficiency
of cardiac contractions, and to
decrease the hearts workload and
oxygen demand.
7) Emotional stress can produce
vasoconstriction, elevation of BP,
and therefore increase of hearts
workload and rate.
8) A bedside commode decreases
the work and struggle of getting to
the bathroom. Straining causes

Evaluation of Interventions on
Day care is Provided
After these interventions, patients
heart workload has been decreased,
they have been experiencing less
episodes of shortness of breath, and
vital signs are being monitored
every 4 hours.

vagal stimulation which can be

followed by rebound tachycardia
and further compromise cardiac
output.
9) Increases available oxygen for
the heart to combat hypoxia and
ischemia.
10) Diuretics in conjunction with
fluid and sodium restrictions often
lead to improvement of the
patients condition. In this case the
patient is on a loop diuretic which
blocks the absorption of water and
sodium, and they are also on a fluid
restriction of 1800ml. Beta
blockers block the cardiac effects
of chronic adrenergic stimulation,
and increase the patients activity
tolerance and ejection fraction.
Anticoagulants are used to reduce
the risks of thrombus formation in
patients with cardiac dysrhythmias.
DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.

Dumitru, I. (2013). Heart Failure. Retrieved from http://emedicine.medscape.com/article/163062-overview

McLeod, S. (2008). Erik Erikson: psychosocial stages. Retrieved from http://www.simplypsychology.org/ErikErikson.html

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing: preparation for practice. Upper
Saddle River, NJ: Pearson Prentice Hall
United States Department Of Agriculture. (n.d.). SuperTracker. Retrieved 2014, from ChooseMyPlate:
https://www.supertracker.usda.gov/