Professional Documents
Culture Documents
COLLEGE OF NURSING
Student: Vivarian Moulton
1 PATIENT INFORMATION
Patient Initials: RI
Age: 37
Gender: Male
Served/Veteran:
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives with his fianc, 5 children and
his dog and cat. Patient can independently care for himself however
his fianc is there as a secondary caretaker if needed.
Culture/ Ethnicity /Nationality: Hispanic/ Puerto Rican
Religion: Not religious
1 CHIEF COMPLAINT:
Patient states, I was having chest pain, tingling in fingers and jaw pain.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient came to the emergency room on 01/19/2015 after 5 hours of unrelieved, intermittent, nonexertional, anterior chest
pain that was a combination of crushing and sharp, achy. The chest pain was unrelieved by nitroglycerin, relieved on its
own. Patient is post bypass from infancy because of congenital stenosis, multiple ablations for arrhythmias and pacemaker
placement. Two blood tests revealed negative troponin and BNP of 67.8; chest x rays showed symmetrically expanded
with no markings of pneumothorax, consolidation and pleural fluid, the cardio mediastinal structure is within the larger
size of normal limits and an electrocardiogram (EKG/ECG) showed normal sinus rhythm with first degree AV block,
nonspecific ST and T wave abnormalities and PR interval abnormalities. An ultrasound was conducted on 01/20/2015 but
the results were unavailable. The patient was transferred to the telemetry floor on 01/19, placed on tele box 70, and is
being worked up to rule out myocardial infarction. Patient is being continued on aspirin, Coumadin, bisoprolol, and
mexiletine with Lipitor and lovenox added to increase the patients INR from 1.9 to 2.5-3.5. On 01/20 Lisinopril was
added to his treatment plan. Patient has a consult with his pediatric cardiologist for evaluation and is scheduled for a stress
test today.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Father
62
Mother
58
Sister
38
Sister
41
Tumor
Stroke
Stomach Ulcers
Seizures
Kidney
Problems
Mental Health
Problems
Hypertension
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Cause
of
Death
(if
applicable)
Anemia
2
FAMILY
MEDICAL
HISTORY
06/28/2012
09/09/2013
unknown
Environmental
Allergies
Operation or Illness
Congenital Heart Disease
Valvular Heart Disease
Bypass surgery
Aortic Valve Replacement
Diagnostic u/s of the heart, cardiac mapping, excision of tissue of heart: endovascular approach,
catheter based invasive electro physiologic testing
Paralyzed diaphragm- resolved
Automatic implantable cardioverter defibrillator placement
Gurd
Three ablations of the left ventricle due to arrhythmias
Alcoholism
Date
07/24/1977
07/24/1977
Infant
06/01/1993
06/28/2012
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? U
Influenza (flu) (Date) Is within 1 years? 2013, patient refused the vaccine
upon admission to hospitals
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
YES
NO
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
NAME of
Causative Agent
N/A
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)
Mechanics of disease: Angina is chest pain that occurs when the hearts demand for oxygen is not met, there is
insufficient blood flow to the heart. Stable angina is predictable and normally occurs when your heart is working hard and
needs more oxygen. With stable angina, the symptoms goes away with rest. Unstable angina is unexpected and does not
relieve with rest or nitroglycerin. Unstable angina (UA) is reoccurring and occurs with minimum or no exertion. It is an
indication that a heart attack is forthcoming. According to WebMD, Unstable angina presents with symptoms of a heart
attack to include squeezing or sharp chest pains, pain that radiates to extremities and/or back, nausea, anxiety, sweating,
shortness of breath, dizziness, unexplained fatigue (K Pai, 2014). Coronary artery disease (CAD) is the main cause of
unstable angina. CAD causes a buildup of plague in arteries which cause them to become narrow, restrict blood flow and
cause chest pain. Unstable angina is warning that if left untreated a heart attack may occur (Hall, 2012). UA can be
differentiated from non St elevation myocardial infarction by the absence of abnormal cardiac markers.
Risk factors: Risk factors for UA include elderly men and women, high blood pressure, tobacco use, diabetes,
dyslipidemia, smoking, family history of early coronary artery disease (CAD), sedentary lifestyle, overweight/Obesity,
NSAIDs, lack of exercise, and stress (Hall, 2012).
Diagnose: UA can be diagnosed with blood tests to check for cardiac enzymes which reveal heart damage; an ECG to
monitor heartbeats and irregularities that may indicate reduced blood flow; echocardiography for images of your heart;
stress tests to detect angina; coronary angiography uses x rays to study arteries for any blockages and narrowing; cardiac
catheterization and fasting lipid profile (Joffe, 2012).
Treatment: Treatment for UA is to prevent heart attack from occurring. Recommended treatment includes blood thinners,
beta blockers, possible angioplasty, heart bypass, bed rest with heart monitoring, as needed (PRN) antiarrhythmics, PRN
anxiolytics, deep vein thrombosis prevention, cardiac rehabilitation, smoke cessation, annual influenza vaccine. Oxygen
and pain relief and nitroglycerin are a part of the first line of treatment (Joffe, 2012).
Prognosis: The prognosis of patients with UA is of a lower in hospital mortality than those with ST elevation myocardial
infarction, however, the long term outcome is similar. How long a patient survives with UA depends on various factors
such as the number of blocked arteries, history of heart attacks, and the hearts ability to pump blood. UA may cause heart
attack, heart failure and dysrhythmias which may cause patients to die unexpectedly (Joffe, 2012).
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name: aspirin
Trade name: ASA
Route: PO
Concentration
Home
Hospital
or
Both
Indication: The patient presented to the hospital with symptoms of possible myocardial infarction, this medication is for the prophylaxis of myocardial
infarctions and transient ischemic attacks by preventing platelet aggregation.
Adverse/ Side effects: Patient may experience tinnitus, GI bleeding, vomiting, hepatotoxicity, anemia, rash, allergic reactions to include anaphylaxis and
laryngeal edema.
Nursing considerations/ Patient Teaching: Onset is 5-30 minutes with and patient will begin to feel maximum effect 1-3 hours for 3-6 hours. Contraindicated in
patients who are taking other forms of blood thinners as it increases the risk of bleeding. May cause GI irritation so take with food or with a full glass of water.
May cause lengthen bleeding time so prolonged prothrombin time should be monitored. Avoid concurrent use of alcohol to help minimize GI irritation.
Name: atorvastatin
Trade name: Lipitor
Route: PO
Concentration
Dosage Amount: 40 mg
Frequency: Once daily
Adverse/ Side effects: Dizziness, headache, rhinitis, chest pain, increased liver enzymes, constipation, hyperglycemia, erectile dysfunction, rashes,
Rhabdomyolysis, and angioneurotic edema are some effects of taking this medication that the patient may experience.
Nursing considerations/ Patient Teaching: Taking this medication may increase the effects of warfarin. Evaluate cholesterol before initiating and periodically
afterwards. Monitor liver function tests prior to and during therapy. If muscle tenderness develops CPK levels should be monitored. Patient should notify
health care professional if unexplained muscle tenderness, pain or weakness occurs.
Name: bisoprolol
Trade name: Zebeta
Route: PO
Concentration
Dosage Amount: 5 mg
Frequency: Once daily
Home
Hospital
or
Both
Indication: This will help manage the patients hypertension by decreasing blood pressure and heart rate.
Adverse/ Side effects: Patient may experience fatigue, weakness, anxiety, blurred vision, bronchospasm, bradycardia, constipation, increased liver function tests
(LFT), decreased libido, rash, glycemic changes, and back pain.
Nursing considerations/ Patient Teaching: Patient should feel maximum effect within 4 hours and should last approximately 24 hours. Avoid usage of alcohol as
it may cause hypotension. Patients blood pressure, ECG and pulse should be monitored frequently. This medication may cause increase BUN. Patient should
not stop taking this medication abruptly as it may cause life threatening arrhythmias, hypertension and myocardial ischemia. Patient should notify health care
professional if pulse slows, there is difficulty breathing, wheezing, cold hands and feet, dizziness, light headedness, confusion, depression, rash, fever, sore
throat, unusual bleeding or bruising occurs.
Name: enoxaparin
Trade name: Lovenox
Route: Subcutaneous Injection
Concentration
Concentration
Dosage Amount: 5 mg
Frequency: Once daily
Home
Hospital
or
Both
Indication: When used in conjunction with other antihypertensives this medication will help manage hypertension by lowering blood pressure.
Adverse/ Side effects: The patient may experience dizziness, fatigue, cough, hypotension, chest pain, diarrhea, rashes, hyperkalemia and angioedema.
Nursing considerations/ Patient Teaching: This medication will become effective within one hour and achieve therapeutic effect in 6 hours and will last for 24
hours. Nurse should monitor blood pressure (BP) and pulse and notify health care professional of significant changes. Monitor kidney functions. Patient should
notify HCP if rash, mouth sores, sore throat, fever ,sweating of hands and feet, irregular heartbeat, chest pain, dry cough, hoarseness, swelling of face, eyes, lips
or tongue or if difficulty swallowing or breathing occurs.
Name: mexiletine
Trade name: Mexitil
Route: PO
Concentration
Home
Hospital
or
Both
Indication: This medication is for the treatment and prevention of serious ventricular arrhythmias.
Adverse/ Side effects: Side effects that this patient may experience include dizziness, nervousness, confusion, blurred vision, dyspnea, arrhythmias, chest pain,
heartburn, rashes and tremor.
Nursing considerations/ Patient Teaching: This medication starts to take effect within 30 minutes 2 hours with maximum effect within 2- 3 hours and lasts for
8-12 hours. The nurse should monitor pulse, BP, ECG and chest x rays to help adjust dosages. Monitor for an increase in AST enzyme. Patients should be
taught how to monitor pulse and to contact HCP if pulse rate is less than 50 beats per minute or becomes irregular.
Name: nitroglycerin
Trade name: Nitrostat
Route: sublingual
Concentration
Home
Hospital
or
Both
Indication: This medication relieves myocardial oxygen consumption to prevent or relieve angina attacks.
Adverse/ Side effects: The patient may experience side effects of dizziness, headache, restlessness, blurred vision, hypotension, tachycardia, nausea, and
vomiting.
Nursing considerations/ Patient Teaching: This medication has a rapid onset that occurs within 3 minutes and the effects can last 30-60 minutes. The patient
should be aware that tablet should not be swallowed or crushed but should be allowed to dissolve under the tongue. The nurse should be aware that 3 doses of
this medication should be administered 5 minutes apart or until chest pain resolves. Patient should be aware that they may experience the worst headache of
their life. The nurse should monitor BP and pulse before and after administration. The nurse should also assess the patients angina pain.
Name: ondansetron
Trade name: Zofran
Route: IV Injection
Concentration
Home
Hospital
or
Both
Indication: This medication is for the prevention of any nausea and vomiting the patient may experience.
Adverse/ Side effects: Patient may experience headache, dizziness, QT interval prolongation, constipation, diarrhea, extrapyramidal reactions and an increase
in liver enzymes.
Nursing considerations/ Patient Teaching: The onset of this medication is rapid with a peak of 15- 30 minutes that may last 4-8 hours. The nurse should assess
patient for nausea, vomiting, abdominal distention and bowel sounds prior to and after administration. Patient should be instructed to notify HCP if irregular
heart beat or involuntary movement of eyes, faces, or limbs occur.
Name: warfarin
Trade name: Coumadin
Route: PO
Pharmaceutical class: coumarins/ anticoagulants
Concentration
Dosage Amount: 8 mg
Frequency: Once daily
Home
Hospital
or
Both
Indication: The patient had a pacemaker placed and this medication will help in preventing formation of thrombus and embolization after valve replacement.
Adverse/ Side effects: Patient may experience cramps, nausea, bleeding and fever.
Nursing considerations/ Patient Teaching: This medication has an onset of 36-72 with a peak duration within 5-7 days with constant usage and this effect can
last 2-5 days. This drug will increase the response to warfarin and increase the risk of bleeding when used with NSAIDs and aspirin. The patient should tell the
HCP if they are using anise, arnica, chamomile, clove, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, licorice as these may also increase
risk of bleeding. The nurse should assess for bleeding and hemorrhage such as bleeding gums, nosebleed, unusual bleeding, tarry- black stools, hematuria, fall in
hematocrit or BP, urine or nasogastric aspirate. Monitor PT, INR and other clotting factors. Patient should report any symptoms of unusual bleeding and
should not drink alcohol or other medications unless prescribed by HCP.
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: On a typical morning, the patient eats one slice
of ham cold cuts and one slice of American cheese
sandwich on two slices of white toasted bread with an 8
ounce of decaffeinated coffee containing milk and sugar.
Lunch: For lunch, the patient eats two ham and cheese
sandwiches with mayo.
Dinner: For dinner the patient may consume a handful of
white rice, roasted pork with avocado salad with no
dressing.
Snacks: The patient does not normally eat snacks
throughout the day as he doesnt get hungry.
Liquids (include alcohol): The patient consumes about
three cups of 16 ounce water throughout the day.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? The patient states, my fianc and children, my parents live down South so they cant
help much.
How do you generally cope with stress? or What do you do when you are upset? The patient states that he, secludes
himself.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) The patient
denies any recent difficulties.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Autonomy vs.
Generativity vs.
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: According to Social Work Perspectives on Human Behaviour, the stage of generativity versus stagnation is
defined by making contributions to family and society. This stage is marked by the individuals ability to raise a family and work, to
meet their needs and those of others with a balance. Generativity encompasses an ability to foresee and hope for the future. The central
point is parenting and productivity with a desired outcome of care and possibility of having negative outcomes to include overextension, exhaustion, and rejection (Parrish, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient is in the generativity stage. He is was a part of the workforce for years before moving to Florida and now he is
an active parent in his childrens life. Although he is not working, he still meets the needs of his family.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The main impact the complications of his heart condition has had on his life is impeding his ability to be a part of the
workforce but the patient has taken it all in stride and displays no regret or bitterness.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
The patient states that he does not know what the cause of his illness is. There is no history of heart conditions in his
family and he was the only one born with any illness.
What does your illness mean to you?
The patient states, I was born with it, I had my first operation at 2 years old, it is a part of my life.
+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? The patient prefers 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? The patient does not know._____________________________
Are you currently sexually active? Yes________________________ If yes, are you in a monogamous relationship?
__Yes________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? None__________________________
How long have you been with your current partner?5 years._________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? The patient states that it definitely
has not.__________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
Yes
No
For how many years? 20 years
(age 12
thru 32
Pack Years: 1
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? 6 beers
Scotch:
Volume: 16 ounce glass of scotch
Frequency: scotch at least once per
week
If applicable, when did the patient quit? N/A Socially: Beer once every 3 months.
thru
presently
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much?
For how many years? 12
(age 20
thru 32
)
2 blunts per day
Is the patient currently using these drugs?
Yes No
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
5. For Veterans: Have you had any kind of service related exposure? Not applicable.
10
Immunologic
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Two years ago
Other:
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: A+
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
4x/day
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 01/19/2015
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
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
Osteomyelitis
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
11
Arthritis
Other:
Chicken Pox
Other:
General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health? Patient states that his health is as good as can be with everything thats going on.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No
Any other questions or comments that your patient would like you to know?
No
12
10 PHYSICAL EXAMINATION:
General Survey: Patient
Height: 175.26 inches Weight: 215 pounds/
BMI: 32
Pain: (include rating and
is well developed 36 year
97.471 kg
location) O
old who is slightly
Pulse: 89
Blood Pressure: (include location)
overweight.
111/74 left arm
Respirations: 17
Temperature: (route
SpO2: 98
Is the patient on Room Air or O2 :
taken?) 98.2 oral
Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
flat
loud
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 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 24 inches & left ear- 24 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL: clear
LUL: clear
RML : clear
LLL: clear
RLL: clear
Chest expansion
Cardiovascular:
13
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No JVD
or
mLs N/A
with assistance
Biceps: 2
Brachioradial:
Patellar: 2
Achilles:
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
University of South Florida College of Nursing Revision September 2014
14
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.
Lab
WBC: 6.0
Normal: 4.511.1
Dates
01/19/2015
Trend
Upon admission, the
patients WBCs were
within normal limits.
HGB: L13.9
Normal: 11.716.1 g/dL
01/19/2015
PLT: 196
Normal: 150450
103/microL
01/19/2015
Coagulation:
PT: H21.9
INR: 1.9
APTT: H36.1
01/19/2015
01/19/2015
01/19/2015
Analysis
High WBC indicate an
infectious process is
ongoing. The patients
normal levels indicate an
absence of infection
(Vallerand, 2014).
Low HGB indicates
oxygen isnt being
circulated as it should
hence causing the organs
to not be adequately
perfused. The patients
HGB levels could be an
indicator of oxygenation
problems (Vallerand,
2014).
PLTs are an important
factor in the bodys
clotting mechanism. The
patient is on blood
thinners. If there are not
enough PLTs, the patient
may bleed and/ or bruise
easily. The inverse of
having too high a levels
of PLT would contribute
to blood clots and
arteriosclerosis. The
patients levels were
normal (Vallerand, 2014).
The patient is on multiple
medications that may
affect his bodys clotting
mechanism. Aspirin may
increase PT and warfarin
requires monitoring of
clotting factors. The
patients lengthened
clotting time is a side
effect of his blood
thinners and an indication
that his medication
15
01/19/2015
Creatinine: 0.87
normal(0.5-1.4 mg/dl)
01/19/2015
Troponin-I: <0.015
0.015
01/19/2015
01/20/2015
BN Peptide: 67.8
<100 indicate no HF,
100-300 suggest heart
failure is present
LFT: Test not done
AST
ALT
01/19/2015
N/A
16
N/A
Chest X ray conducted on 01/19/2015 because of chest pain revealed symmetrical lungs without consolidation,
pneumothorax or pleural fluid. Cardio mediastinal silhouette size is on the larger side of normal size. The
presence of a dual lead upper chest wall cardiac pacer was seen. Median sternotomy was done. The general
impression of this x ray confirmed there was no cardiopulmonary process.
Electrocardiogram was done on 01/19/2015 and showed a heart rate of 82, normal sinus rhythm with a first
degree AV block, St and T wave abnormalities, abnormal PR interval of 232 and normal QRS duration of 110.
Normal sinus rates would have revealed a PR interval of 0.12-0.21, QRS duration of 0.06- 0.12
Ultrasound was done on 01/20/2015 but the results were not interpreted before clinical day ended.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,
multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently on vital signs every 4 hours. He is also on a cardiac diet during his hospital stay.
The patient is not on fall risk precautions and can ambulate independently. The patient was scheduled for
a stress test and was awaiting a consult with his pediatric cardiologist before he would be discharged from
the hospital.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. At risk for bleeding r/t impaired clotting aeb patient confirmation of bleeding and bruising easily.
2. Imbalanced nutrition: more than body requirements r/t poor dietary intake aeb BMI over 25
3. Decreased cardiac output r/t cardiac dysfunction (dysrhythmia) aeb ECG reading and patients complaint chest pain
4. Activity intolerance r/t sedentary lifestyle aeb patient fatigue upon exertion
5. Risk for decreased cardiac tissue perfusion r/t pacemaker malfunction
17
15 CARE PLAN
Nursing Diagnosis: At risk for bleeding r/t impaired clotting aeb patient confirmation of bleeding and bruising easily.
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
The patient will maintain stable
-Assess client for signs and
- By knowing the early and late
-There was no change in the
vital signs during time on floor.
symptoms of unusual bleeding
signs and symptoms of bleeding
patients vital signs, goal was met.
such as decreased B/P, bruising
the nurse can correct it from
and increase pulse rate and a
earlier.
decrease in hematocrit and
-Watch for changes associated with
hemoglobin levels.
bleeding including increased heart
-Check vital signs at frequent
rate, respiratory rate, and
intervals
eventually decreased blood
-Implement measures to prevent
pressure.
bleeding such as using the smallest - Preventing bleeding will help the
gauge needles and apply gentle
patient maintain stable vital signs
prolonged pressure to the site after
(Pomeroy, 2011).
needle is removed)
Lab values related to bleeding will - Monitor laboratory tests including - INR and PT measure the effects
- The patients PT and aPTT values
remain normal throughout hospital hematocrit, hemoglobin, INR, PT.
of medication on the coagulation
were slightly elevated, this goal is
stay.
-Monitor medications for effects on cascade and should be drawn at
still in progress and hence has not
increasing bleeding including
least 16 hours after the dose is
been met.
aspirin and NSAIDs.
administered.
-These medications have an
antiplatelet effect that can increase
the risk of bleeding especially in a
client who is at risk due to illness
or medications.
(Pomeroy, 2011).
Patient to prevent bleeding after
- **Educate patient on signs such
- Shave with an electric razor.
-Goal not met, the patient has been
discharge from hospital.
as nosebleed and abnormal
Brush teeth with a soft toothbrush. discharged from the hospital as yet.
bruising.
Wipe with wet wipes after stooling.
- Advise patient to adopt safety
Avoid sports and activities that
practices about self- care activities. could increase the patients risk for
-**Teach patient to monitor the
falling.
University of South Florida College of Nursing Revision September 2014
18
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 - yes
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments - yes
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Nursing Diagnosis: Imbalanced nutrition: more than body requirements r/t poor dietary intake aeb BMI over 25
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will recognize measures
-Document weight.
- Patient may be unaware of actual -This goal was met as patient was
necessary to achieve weight
-Familiarize the patient with selfweight and will be able to track
able to demonstrate understanding
reduction during shift.
monitoring of food intake
progress.
of measures necessary to achieve
including keeping a food and
- A Cochrane review found that
weight reduction.
exercise diary.
cognitive behavior therapy when
-Planning food intake for each day. combined with a diet and exercise
- Encourage client to increase
intervention resulted in more
intake of vegetables and fruits to at weight loss than diet and exercise
least five servings per day.
alone.
-A study demonstrated that
University of South Florida College of Nursing Revision September 2014
19
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 - yes
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
University of South Florida College of Nursing Revision September 2014
20
Rehab/ HH
Palliative Care
21
References
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Retrieved February 14, 2015,from http://www.nlm.nih.gov/medlineplus/ency/article/007452.htm
Derrer, D. (2013, March 27). Tests for high cholesterol (lipid panel). Retrieved February 14, 2015, from
http://www.webmd.com/cholesterol-management/tests-for-high-cholesterol-lipid-panel?page=2
Joffe, MD, S., & Berk, MD, L. (2012, January 1). Acute coronary syndromes: unstable angina and nstemi.
Retrieved February 12, 2015, from http://nursing.unboundmedicine.com/nursingcentral/view/5-MinuteClinical-Consult/117673/all/Acute_Coronary_Syndromes:_Unstable_Angina_and_
NSTEMI?q=unstable angina
K. Pai., R., Fort., & Healthline Staff (2014, March 12). heart attack and unstable anginatreatment overview. Retrieved February 12, 2015, from http://www.webmd.com/heart-disease/tc/heartattack-and-unstable-angina-treatment-overview
"MyPlate.gov" SuperTracker. united states department of agriculture. Web. 21 November 2014.
<https://www.supertracker.usda.gov/foodtracker.aspx
Parrish, M. (2014). Freud's psychoanalytical and Erikson's developmental theories of behaviour. In social work
perspectives on human behaviour (2nd ed., pp. 77-82). Maidenhead: McGraw-Hill Education.
Pietrangelo, A., & Krucik, (2013, January 20). Coagulation tests. Retrieved February 16, 2015,
from http://www.healthline.com/health/coagulation-tests#Types3
Pomeroy, S. & Ackley, B. J., Ladwig, G. B., (2011). Risk for bleeding and imbalanced nutrition: more than
body requirements. Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.,
p169- 171) (p582-587). Maryland Heights, Mo.: Mosby.
Thompson, MD, E., O'Donnell, MD, J., & Staff, H. (2014, March 12). Partial thromboplastin time. Retrieved
February 14, 2015,from http://www.webmd.com/a-to-z-guides/partial-thromboplastin-time?page=2
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Vallerand, A., Sanoski, C., & Deglin, J. (2014). [aspirin (ASA) to warfarin (Caumadin)] [Normal values of
common laboratory tests] Daviss Drug Guide. Unbound Medicine, Inc. [Software]. Retrieved from
http://www.unboundmedicine.com/products/nursing_central
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