Patient Assessment Tool ms1

UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Danielle Giaritelli
PATIENT ASSESSMENT TOOL . Assignment Date: November 16,

2014
Agency: USF
1 PATIENT INFORMATION
Patient Initials:
RA
Gender:
male
Age: 60
Admission Date: 10/5/2014
Marital Status: single
Primary Medical Diagnosis with ICD-10 code:
Primary Language: Spanish or English
Acute CVA I63.9
Level of Education: 1st year of college
Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): sergeant in military
N/A
Number/ages children/siblings: 1 daugher-age 32
Served/Veteran: yes
Code Status: full recessitation
Living Arrangements: home alone in a 1 story house
Advanced Directives: no
If no, do they want to fill them out? no
Surgery Date:
N/A
Procedure: N/A
Culture/ Ethnicity /Nationality: Puerto rican

Religion: catholic
Type of Insurance: Medicaid
!1
University of South Florida College of Nursing Revision August 2013
1 CHIEF COMPLAINT: Patient complained of dizziness, weakness, and a severe headache 2 days
Before admission. He denied feeling any pain.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient is a 60 year old male who presented to the Emergency Room with complains of gait disturbance, headache,
weakness, and vertigo. He felt dizzy when moving. He felt these symptoms on October 3rd and thought they would go
away. When they persisted for two days, he called 911. The symptoms continued to worsen. They started on October 3
at
7 pm while the patient was cooking dinner. He felt the symptoms all over but more severe on the left side. They were
constant but fluctuated in intensity. He felt a spinning sensation that worsened when turning his head or moving around.
there wasnt anything that made it better and it only got worse when he tried to lie down. Patient was supposed to be
taking Coumadin 4mg daily at home, but denied taking it for the past month.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
Operation or Illness
2012
Acute CVA
2012
Coronary Artery Bypass Graft
2012
Heart Failure
November 6, 2012 Coronary Artery Disease and Deep Vein Thrombosis

February 4, 2014
Dyslipidemia, Chronic Heart Failure, Hypertension
!2
2
FAMILY
MEDICA
L
HISTOR
Y
Ag
e
(in
ye
ars
)
Cause
of
Death
(if
applicable
)
Father
81
Stroke
Mother
43
Bypass
Surgery
Brother
51
N/A
Al
co
hol
is
m
Env
iron
men
tal
Alle
rgie
s
A
ne Art As
m hri th
ia tis ma
Bl
ee
ds
Ea
sil
y
Ca
nc
er
Di
ab
ete
s
Hea
rt
H
Tro
yp
Gl
G
uble
er
au
ou
(angi
te
co
t
na,
ns
ma
MI,
io
DVT
n
Kid
ney
Pro
ble
ms
etc.)
Me
nta
l
Sto
He
ma
alt Sei ch Stro Tu
zur Ul ke
h
mor
Pr es cer
obl
s
em
s
Sister
relationship
relationship
relationship
Comments: Include date of onset
IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
NO
Routine childhood vaccinations

Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) Unknown
Adult Tetanus (Date) Unknown
!3
Influenza (flu) (Date) 2014

Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
Type of Reaction (describe explicitly)

No known allergies.
Medications
No known allergies.
Other (food, tape,
latex, dye, etc.)
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)
When an ischemic stroke occurs, the blood supply to the brain is obstructed and the brain cells arent getting the oxygen
And glucose needed in order to function. The primary reason of stroke is because of an underlying blood vessel or heart
Disease that can cause the interruption of blood flow. A thrombotic stroke occurs when a thrombus, blood clot, forms in
the arties that supply the blood to your brain. It can be caused by plaque build up, fat deposits, that build up in the artery
and cause reduced blood flow. The manifestations that occur with a stroke in the brain are a result Of the underlying
disease. The most common causes are hypertension, atherosclerosis, dyslipidemia, and heart disease.
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
!4
Name amlodipine (Norvasc)
Concentration (mg/ml)
Route PO
Dosage Amount (mg) 5mg

Frequency daily
Pharmaceutical class calcium channel blockers
Home
Hospital
or
Both
Indication management of hypertension, angina pectoris, and vasospastic angina

Side effects/Nursing considerations dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, nausea
Name aspirin (ASA)
Concentration
Route PO
Dosage Amount 325mg

Frequency daily
Pharmaceutical class salicylates
Home
Hospital
or
Both
Indication prophylaxis of transient ischemic attacks and myocardial infarction

Side effects/Nursing considerations tinnitus, GI bleed, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, vomiting, laryngeal edema, rash
Name carvedilol (Coreg)
Concentration
Route PO
Dosage Amount 6.25mg

Frequency BID
Pharmaceutical class beta blocker
Home
Hospital
or
Both
Indication hypertension, heart failure

Side effects/Nursing considerations bradycardia, heart failure, pulmonary edema, stevn-johnsons syndrome, toxic epidermal necrolysis, itching, anxiety,
weak
Name docusate (Colace)
Concentration
Route PO
Dosage Amount 100mg

Frequency BID
Pharmaceutical class stool softener
Home
Hospital
or
Both
Indication prevention of constipation

Side effects/Nursing considerations throat irritation, mild camps, diarrhea, rashes
Name simvastatin (Zocor)
Concentration
Route PO
Dosage Amount 40mg

Frequency QHS
Pharmaceutical class hmg coa reductase inhibitor
Home
Hospital
or
Both
Indication management of primary hypercholesterolemia and mixed dyslipidemias

Side effects/Nursing considerations amnesia, confusion, cramps, constipation, heart burn, flatus, rhabdomyolysis, rashes, erectile dysfuncion
Name warfarin (Coumadin)
Concentration
Route PO
Dosage Amount 4mg

Frequency daily
Pharmaceutical class anticoagulant
Home
Hospital
or
Both
Indication prophylaxis of pulmonary embolism, management of myocardial infarction

Side effects/Nursing considerations cramps, nausea, dermal necrosis, bleeding, fever
Name
Route
Concentration
Dosage Amount
Frequency
!5
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Route
Dosage Amount
Frequency
Home
Hospital
or
Both
Indication
Name
Concentration
Route
Dosage Amount
Frequency
Home
Hospital
or
Both
Indication
Name
Concentration
Route
Dosage Amount
Frequency
Home
Hospital
or
Both
Indication
!6
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with
recommendations.
Diet ordered in hospital?

diet
Heart Healthy cardiac
Diet pt follows at home? Pt doesnt follow diet at home
Analysis of home diet (Compare to My Plate and

Consider co-morbidities and cultural considerations):
24 HR average home diet:

Breakfast: 2 slices of pork bacon, 2 scrambled eggs, 1 slice
Whole wheat toast
Lunch: 1 medium fried chicken breast with 1 serving of
mashed potatoes
Dinner: 2 cups of spaghetti, with tomato sauce, and 2 meat

balls
Snacks: pt does not eat snacks
Liquids (include alcohol): pt only drinks water
!7
The patient does not follow a specific diet at home.

When asking the patient about his diet, he told me what he
would eat in a normal day at home. He doesnt reach his
maximum caloric level, however, he only eats three meals
a day and doesnt like to eat snacks. It is recommended
that a person eat 5-6 small balanced meals a day, so
educating the patient on this could help with the patients
metabolism and a healthier lifestyle.
The patient is getting adequate whole grains, and
protein, but could use more vegetables. Instead of having
mashed potatoes with his lunch, he could have a sweet
potato and add broccoli or spinach. The patient is getting
no fruit in his diet, so recommending the patient to add
fruit in between meals could help with snacking and
adding enough fruit to the diet. The patient also does not
get enough dairy. The patient could add a glass of milk
with breakfast or a yogurt as a snack. This would provide
calcium and more protein.
The patient got a good amount of oil and saturated fat,
however was 1697mg over on sodium. Reducing the
amount of butter and margarine used to prepare meals
could overall decrease the amount of sodium in the diet.
With the high amount of sodium, it is imperative the
patient knows how important it is to constantly stay
hydrated.
Because of the patients underlying health conditions,
coronary artery disease and dyslipidemia, it is important he
knows healthier meal options. For breakfast, instead of two
scrambled eggs, he could switch to egg whites. For lunch,
instead of fried chicken he could have baked or grilled and
add a steamed vegetable instead of mashed potatoes. For
dinner he could substitute traditional pasta for spaghetti
squash making it a healthier dish made of vegetables.
Making these changes could significantly decrease
worsening the disease processes and prolonging his life.
Who helps you when you are ill? No one. I take care of myself.
How do you generally cope with stress? or What do you do when you are upset? I play with my three dogs and find
some
way to distract myself. I also go visit my dad to keep me happy. I try to stay busy.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) No.
!8
+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? ____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? I am not currently in one.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust
Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority
Identity vs. Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for
your
patients age group: Middle-aged adults must feel that they are producing something that will outlive them, either as parents or as
Workers; otherwise they will become stagnant and self centered.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
I think the patient is in the generativity stage of his life. The patient patient had a cheerful affect and was eager to talk.
He
took a lot of pride in raising his dogs and his daughter. He didnt say what happened to his wife, but he still visits his
daughter and she comes to visit him. He likes spending time with his daughter and dogs and did not seem self centered
at
all.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patients disease did not have an impact on his stage of life because he was still happy even during his stay. He said
He doesnt let things get in the way of his life because it is out of his control.
+3 CULTURAL ASSESSMENT:
!9
What do you think is the cause of your illness? It could have been things that I have done in the past, but it also just
a part of life.
What does your illness mean to you? I think it may be a wake up call and a sign to take better care of myself.
+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__________________________________________________________

Do you prefer women, men or both genders? women____________________________________________________
Are you aware of ever having a sexually transmitted infection? __no________________________________________
Have you or a partner ever had an abnormal pap smear?_______no________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _______no_____________________________
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? _________N/A_________________
How long have you been with your current partner?_______________N/A______________________________
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
!10
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? It doesnt have an importance in my life.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition? No.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
Yes
How much?(specify daily amount)
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?
Has the patient ever tried to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? beer
Yes
No
How much? (give specific volume)
For how many years?
About 2, 12 oz beers a day
(age 30
thru
current
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
!11
no
!12
10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Immunologic
Recent weight loss or gain
Nausea, vomiting, or diarrhea
Chills with severe shaking
Integumentary
Constipation
Irritable Bowel
Night sweats
Changes in appearance of skin
GERD
Cholecystitis
Fever
Problems with nails
Indigestion
Gastritis / Ulcers
HIV or AIDS
Dandruff
Hemorrhoids
Blood in the stool
Lupus
Psoriasis
Yellow jaundice Hepatitis
Rheumatoid Arthritis
Hives or rashes
Pancreatitis
Sarcoidosis
Skin infections
Colitis
Tumor
Diverticulitis
Life threatening allergic reaction
Bathing routine: every morning
Appendicitis
Enlarged lymph nodes
Other:
Abdominal Abscess
Other:
Use of sunscreen
SPF:
Last colonoscopy? Never got one
HEENT
Other:
Hematologic/Oncologic
Difficulty seeing-wears glasses
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: A+
Post-nasal drip
Normal frequency of urination:

day
Oral/pharyngeal infection
Bladder or kidney infections
3 x/
Other:
Metabolic/Endocrine
Dental problems
Routine brushing of teeth
2 x/day
Diabetes
Type:
Routine dentist visits
2 x/year
Hypothyroid /Hyperthyroid
Vision screening
Intolerance to hot or cold
Other:
Osteoporosis
Other:
Pulmonary
Central Nervous System
Difficulty Breathing
Cough - dry
Asthma
or
productive
WOMEN ONLY
Infection of the female genitalia
CVA
Dizziness
!13
Bronchitis
Monthly self breast exam
Severe Headaches
Emphysema
Frequency of pap/pelvic exam
Migraines
Pneumonia
Date of last gyn exam?
Seizures
Tuberculosis
menstrual cycle
Environmental allergies
menarche
age?
Encephalitis
last CXR? 2014
menopause
age?
Meningitis
Other:
Date of last Mammogram &Result:
regular
irregular
Ticks or Tremors
Other:
Date of DEXA Bone Density & Result:
Cardiovascular
MEN ONLY
Mental Illness
Hypertension
Infection of male genitalia/prostate?
Depression
Hyperlipidemia
Frequency of prostate exam? Never got

one
Schizophrenia
Date of last prostate exam? N/A
Chest pain / Angina
Anxiety
Myocardial Infarction
BPH
Bipolar
CAD/PVD
Urinary Retention
Other:
CHF
Musculoskeletal
Murmur
Injuries or Fractures
Childhood Diseases
Thrombus
Weakness
Measles
Rheumatic Fever
Pain
Mumps
Myocarditis
Gout
Polio
Arrhythmias
Osteomyelitis
Scarlet Fever
Last EKG screening, when? 2014
Arthritis
Chicken Pox
Other:
Other:
Other:
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
no
!14
Any other questions or comments that your patient would like you to know?
no
!15
10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: 60-year-old Height: 170cm
male; overweight; wellPulse:74
groomed
Weight: 86.9kg
Temperature: (route taken?)
(include location) 170/90 ; right arm
Respirations: 23
SpO2 98%
Blood
Pressure:
BMI: 31.8 Pain: (include rating & location)

N/A
Is the patient on Room Air or O2:
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

apathetic bizarre
cooperative
agitated
anxious
cheerful
tearful
talkative
withdrawn
quiet
boisterous
flat
aggressive hostile loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Peripheral IV site
Type:
20 gauge Double Lumen
Location: Right Antecubital Date inserted: 10/5/2014 at 1700
no redness, edema, or discharge

Fluids infusing? no
yes - what?
!16
Peripheral IV site
Type:
Location:
Date inserted:
no redness, edema, or discharge

Fluids infusing? no
yes - what?
Central access device Type:

Fluids infusing? no
Location:
yes - what?
HEENT: Facial features symmetric

Thyroid not enlarged
Date inserted:
No pain in sinus region No pain, clicking of TMJ
No palpable lymph nodes
Trachea midline
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3 mm
Patients right eye is a fake eye.
Peripheral vision intact
Ears symmetric without lesions or discharge
EOM intact through 6 cardinal fields without nystagmus
Whisper test heard: right ear-
12
inches & left ear- 12
inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
!17
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:
Color: white
CR - Crackles
thick
pale yellow
thin
Amount: scant small
yellow dark yellow green
gray
moderate large
light tan brown
red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds: S1 S2
Regular
PMI felt at: Mitral Valve

No murmurs, clicks, or adventitious heart sounds
Irregular
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
Calf pain bilaterally negative

Apical pulse: +2
+2
Carotid:
No temporal or carotid bruits

Location of edema:
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
+2
Brachial: +2
Edema:
0
pitting
Radial: +2 Femoral:
+2 Popliteal:
+2 DP: +2 PT:
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm),
+4(7-8mm) ]
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU: Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
!18
Urine output: Clear

Foley Catheter
Cloudy
Color:
Urinal or Bedpan
yellow
Previous 24 hour output: N/a
Bathroom Privileges
without assistance
or
mLs N/A
with assistance
CVA punch without rebound tenderness

Last BM: (date
Watery
10 /
Color: Light brown
2014 )
Medium Brown
Formed
Dark Brown
Semi-formed
Yellow
Green
Unformed
White
Soft
Hard
Coffee Ground
Maroon
Liquid
Bright
Red
Hemoccult positive / negative (leave blank if not done)
Genitalia: Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other Describe:
Musculoskeletal: Full ROM intact in all extremities without crepitus
Strength bilaterally equal at ___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 parathesias
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Stereognosis, graphesthesia, and proprioception intact

DTR: [rating scale:
Triceps:
+2
Rombergs Negative
Gait smooth, regular with symmetric length of the stride
0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Biceps:
+2 Brachioradial: +2 Patellar: +2 Achilles: +2 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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop)
then include why you expect it to be done and what results you expect to see.
!19
Lab
Dates Trend Analysis
WBC: 7.4 and 8.0

Normal (4.5-11)
10/5/2014 and 10/6/2014
The patients WBC trended upward 1 day after his most
recent labs. The patients WBC is still within normal range, but is on the low side. It could be due to
malnutrition.
RBC:5.04 and 4.64
Normal (4.7-6.1)-male
10/5/2014 and 10/6/2014
The patients RBC has trended downward, possibly
because of medications.
The patient is receiving 325 mg of aspirin daily which is an anticoagulant and
could decrease his RBC causing it to be lower than normal.
Triglycerides: N/A for 10/5/14 and 245
Normal: Less than 150
10/5/2014 and 10/6/2014
There wasnt a baseline on the labs to go off of for
the triglycerides, but it was very high.
The patient has dyslipidemia and is on medication for it that may
or may have not decreased.
HgB: 14.8 and 13.6
Normal (13.5-17.5) 10/5/2014 and 10/6/2014
The patients hemoglobin trended downward since the
first lab.
The patients hemoglobin is still within normal limits but may be on the lower side because of
the anticoagulants.
Hmc: 43.8 and 39.9
Normal (42-54)
10/5/2014 and 10/6/2014
The patients hematocrit trended downwards. Along with
the other blood counts, hematocrit may have lowered because of the anticoagulants-warfarin and aspirin.
!20
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Vitals- they are monitored every 4 hours to watch for side effects from medications and any other
abnormalities
Diet- patient is on a carb conscious diet with up to 60g of carbs per day and low fat, sodium, and
cholesterol. This is the diet because it will help the patient with his high cholesterol and a healthier
lifestyle.
Ultrasound of Carotid Duplex Bilaterally- they did this for a transient ischemic attack and look for
plaque formation. They found it, but there was no flow limiting stenosis.
CT Scan of Brain and Neck without Contract-they did this procedure to compare to the patients stroke
in 2010. This scan showed cerebellum hemisphere infarction, but nothing different than the previous
stroke.
MRAngio of head and neck without contrast- they wanted to compare this test to the CT scan. There
was no occlusion present and it was a normal non contrast MR
NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Impaired mobility r/t acute cerebral vascular attack aeb generalized weakness and dizziness
2. Risk for falls r/t impaired mobility and gait disturbances
3.
4.
5.
!21
15 CARE PLAN
Nursing Diagnosis: Impaired mobility r/t acute cerebral vascular attack aeb generalized weakness and dizziness
Patient Goals/Outcomes Nursing Interventions to
Achieve Goal
Rationale for
Interventions
Provide References
Evaluation of Goal on
Day care is Provided
Increase physical activity

to minimum of 7500 to
10,000 steps per day
Consider use of
constraint-induced
movement therapy, where
the functional extremity is
purposely constrained and
the client is forced to use
the involved extremity.
Constraint therapy is
estimated to benefit about
half of the total CVA
population. The plasticity
of the brain allows the
brain to rewire and
reroute neural
connections to take up the
work of the injured area
of the brain.
Client will be able to

walk better without
assistance and uses all
extremities during
physical activity.
Meet mutually defined

goals of increased
physical activity and
ambulation
Use the Outcome

Expectation for Exercise
Scale to determine
clients self efficacy
expectations and
outcomes expectations
toward exercise.
Findings suggested that

to optimize mobility and
exercise, outcome
expectations for exercise
should be assessed.
Client will be able to

walk better without
assistance and uses all
extremities during
physical activity.
Verbalize less fear of

falling and pain with
physical activity
Monitor and record the

clients ability to tolerate
activity and use all four
extremities; note pulse
rate, blood pressure,
dyspnea, and skin color
before and after activity.
Use valid and reliable

screening procedures and
tools to assess the clients
pre participation in
exercise health screening
and risk stratification for
exercise testing.
Patient will be less fearful

about physical activity
because the health care
provider will have careful
monitored the vitals to
make sure it was safe
before proceeding.
Demonstrate use of
adaptive equipment (e.g.,
wheelchairs, walkers) to
increase mobility
Obtain any assisted

devices needed for
activity, such as gait belt,
weighted vest, walker,
cane, crutches, or
wheelchair, before the
activity begins.
Assistive devices can help If needed, patient will use

increase mobility.
an assisted device to
move around, until
weakness resolves.
!22
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would
include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
!23
15 CARE PLAN
Nursing Diagnosis: Risk for falls r/t impaired mobility and gait disturbances
Achieve Goal
Rationale for
Interventions
Provide References
Evaluation of
Interventions on Day
care is Provided
Client will remain free of

falls
Use a high-risk fall

These steps alert the
armband/bracelet and Fall nursing staff of the
Risk room sign to alert
increased risk of falls.
staff for increased
vigilance and mobility
assistance.
Client and family will be

aware about the fall
reduction measures that
are being used and can be
used at home to prevent
falls.
Environment will be
changed to minimize the
incidence of falls
Thoroughly orient the

client to environment.
Place the call light within
reach and show how to
call for assistance; answer
call light promptly.
The client will better

know his or her
surroundings and
knowing how to use the
call light will reassure the
client will call when help
is needed.
The client will understand

what he or she can do to
change the environment
at home to reduce the
risks of falls.
Explain methods to
prevent injury
Use one quarter- to one

half- length side rails
only, and maintain bed in
a low position, Ensure
that wheels are locked on
bed and commode. Keep
dim light in room at
night.
Use of full side rails can

result in the client
climbing over the rails,
leading with the head, and
sustaining a head injury.
Side rails with widely
spaced vertical bars and
side rails not situated
flushes with the mattress
have been associated with
asphyxiation deaths
because of rail and in bed
entrapment and should
not be used.
The client will be taught

how to safely ambulate at
home, including safety
measures such as
handrails in bathroom,
and need to avoid
carrying things or
performing other tasks
while walking.
Patient will call for

assistance when getting
up or needing help and
wont be afraid to ask for
assistance.
Routinely assist the client

with toileting on his or
her own schedule. Always
take the client to
bathroom on awakening
and before bedtime.
Keep the path to the

bathroom clear, label the
bathroom, and leave the
door open.
Patient will call for

assistance when needing
to get up or use the
bathroom. Patient will
safely make it to and from
where he or she needs to
go.
!24
DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include
for discharge teaching)
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
F/U appts
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis:
!25

Achieve Goal
Rationale for
Interventions
Provide References
Evaluation of
Interventions on Day
care is Provided
DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include
for discharge teaching)
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
F/U appts
Rehab/ HH
Palliative Care
!26
References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(9th ed., pp. 61, 491-495). United States: Mosby, an imprint of Elsevier Inc.
Hinkle, J. (2007, January 1). Medscape Log In. Retrieved November 11, 2014, from
http://www.medscape.com/viewarticle/567653_2
Sigelman, C. K., & Rider, E. A. (2009). Life-span human development (6th ed., pp. 36, 332-334). Australia:
Wadsworth Cengage Learning.
SuperTracker - MyPlate. Retrieved October 3, 2014, from http://www.choosemyplate.gov/supertrackertools/supertracker.html
Vallerand, A. H., & Sanoski, C. A. (2014). 2014 drug information update for Davis's drug guide for nurses,
thirteenth edition and Nurses med deck, thirteenth edition. Philadelphia: F.A. Davis Company.
!27

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UNIVERSITY OF SOUTH FLORIDA

PATIENT ASSESSMENT TOOL . Assignment Date: November 16,

Admission Date: 10/5/2014

Marital Status: single

Primary Medical Diagnosis with ICD-10 code:

Primary Language: Spanish or English

Acute CVA I63.9

Level of Education: 1st year of college

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): sergeant in military

Number/ages children/siblings: 1 daugher-age 32

Code Status: full recessitation

Living Arrangements: home alone in a 1 story house

Culture/ Ethnicity /Nationality: Puerto rican

Type of Insurance: Medicaid

Coronary Artery Bypass Graft

November 6, 2012 Coronary Artery Disease and Deep Vein Thrombosis

Dyslipidemia, Chronic Heart Failure, Hypertension

Comments: Include date of onset

Routine childhood vaccinations

Influenza (flu) (Date) 2014

Type of Reaction (describe explicitly)

Name amlodipine (Norvasc)

Dosage Amount (mg) 5mg

Pharmaceutical class calcium channel blockers

Indication management of hypertension, angina pectoris, and vasospastic angina

Name aspirin (ASA)

Dosage Amount 325mg

Pharmaceutical class salicylates

Indication prophylaxis of transient ischemic attacks and myocardial infarction

Name carvedilol (Coreg)

Dosage Amount 6.25mg

Pharmaceutical class beta blocker

Indication hypertension, heart failure

Dosage Amount 100mg

Pharmaceutical class stool softener

Indication prevention of constipation

Name simvastatin (Zocor)

Dosage Amount 40mg

Pharmaceutical class hmg coa reductase inhibitor

Indication management of primary hypercholesterolemia and mixed dyslipidemias

Name warfarin (Coumadin)

Dosage Amount 4mg

Pharmaceutical class anticoagulant

Indication prophylaxis of pulmonary embolism, management of myocardial infarction

Diet ordered in hospital?

Heart Healthy cardiac

Diet pt follows at home? Pt doesnt follow diet at home

Analysis of home diet (Compare to My Plate and

24 HR average home diet:

Dinner: 2 cups of spaghetti, with tomato sauce, and 2 meat

Liquids (include alcohol): pt only drinks water

The patient does not follow a specific diet at home.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? ______no____________________________________________

Are you currently in a safe relationship? I am not currently in one.

Workers; otherwise they will become stagnant and self centered.

Have you ever been sexually active?_yes__________________________________________________________

How long have you been with your current partner?_______________N/A______________________________

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

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

How much?(specify daily amount)

Have you ever felt unsafe in a close relationship? no______________________________________

How long have you been with your current partner?_N/A________________