UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Elecia Trower

PATIENT ASSESSMENT TOOL .

Assignment Date: 10/15/2014

Agency:

1 PATIENT INFORMATION
Patient Initials: W. C

Age: 53

Admission Date:

Gender:

Marital Status: Divorced

Primary Medical Diagnosis with ICD-10 code:

Male

Primary Language: English

Myocardial Infarction

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Maintenance

Melena (blood in stools)

Number/ages children/siblings: 6 kids ages 22-30

Served/Veteran: No

Code Status: Full Code

Living Arrangements: Lives on his own

Advanced Directives: Non

If no, do they want to fill them out?
Surgery Date: 09/17/2014
Procedure:
Stent placement

Culture/ Ethnicity /Nationality: Black American

Religion: Pentecostal

Type of Insurance: Aetna

1 CHIEF COMPLAINT: Noticed blood in his stools 09/23/2014.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient came to the emergency room on 09/23/2014, because he noticed blood in his stool. He was previously rushed
to the emergency room on 09/17/2014 because of angina pain and tightness in his chest; he was diagnosed as having a
myocardial infarction a stent was placed. Stents are metal mesh that is placed in the coronary artery for support and to
keep it open.
The patient reported that he had no symptoms, the heart attack was sudden, as for the melena it was his first time
experiencing that and he sought medical attention.

University of South Florida College of Nursing Revision August 2013

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

Father

83

Mother

80

Brother

54

Sister

58

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Asthma

Cause
of
Death
(if
applicable
)

Arthritis

2
FAMILY
MEDICAL
HISTORY

Anemia

Strained back

Environmental
Allergies

2005

Alcoholism

Coronary Artery Stent placement.

Age (in years)

09/17/2014

Cancer

Operation or Illness

Bleeds Easily

Date

relationship
relationship
relationship

Comments: Include date of onset

The patients mother abused alcohol from age 20 yrs. to age 60 yrs. She was diagnosed with schizophrenia at a young age .
The patient does know about the onset of illness for other family members.

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)
Adult Tetanus (Date)
Influenza (flu) (Date)
09/17/2014
Pneumococcal (pneumonia) (Date)
09/17/2014
Have you had any other vaccines given for international travel or

YES

University of South Florida College of Nursing Revision August 2013

NO

occupational purposes? Please List

1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

Iodine
Medications

Other (food, tape,

latex, dye, etc.)

Tylenol

Crab

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)
Mechanic of the disease: A myocardial infarction is the irreversible necrosis of heart muscle secondary to
prolonged ischemia, cells are temporarily deprived of their blood supply. They stay alive but cannot function
normally, persistent ischemia leads to an infarction (Huether & McCane. 2012).
Risk Factors : Age, women 55 and older and men 45 and older are at a higher risk. Tobacco, smoking or the
exposure to second hand smoke can damage to the interior wall of arteries. High blood pressure, over time can
damage arteries. High Cholesterol can narrow arteries over time. Other risk factors are diabetes, family history,
lack of physical activity, stress obesity, substance abuse and a history of preeclampsia (Huether & McCane. 2012).
How to Diagnose: Electrocardiogram is the first test done to diagnose a MI other test used are; blood test, chest xray, echocardiogram , coronary cauterization, exercise stress test and Cat scan (Huether & McCane. 2012)
Treatment: The treatment of MIs stent placement or coronary bypass surgery are the more invasive treatments
other treatments are aspirin, super aspirin, thrombolytic, nitroglycerin , beta blockers and other blood thinning
agents (Huether & McCane. 2012)
Prognosis: Myocardial infarction has a 30% mortality rate 1/3 of patients who experience MIs die within 24hr, 510% of the survivors of MIs die within the first year and of all that patients who experienced MIs are
hospitalized within 1 year of the index event ( Maziar Zafari).

University of South Florida College of Nursing Revision August 2013

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

atorvastatin (Lipitor)

Concentration (mg/ml) 40mg

Route Oral

Dosage Amount (mg) 2

tabs

night
Pharmaceutical class hmg cos reductase inhibitors
Home
Hospital
or
Both
Indication primary prevention of coronary heart disease (MI, stroke , angina etc)
Side effects/Nursing considerations Angioneurotic edema, rhabomylysis, hyperglycemia, erectile dysfunction.

Name Lisinopril
Route

Frequency once every

(Zestril)

Concentration 5mg

Oral

Dosage Amount

1 tab

Frequency daily

Hospital
or
Both
ACE inhibitor
Indication management of hypertension and heart failure
Side effects/Nursing considerations Angioedema, hyperkalemia, hypotention, chest pain, headache dizziness.
Home

Pharmaceutical class

Name
Route

metoprolol (Lopressor)

Concentration 25mg

Oral

Dosage Amount
Frequency every

Pharmaceutical class Beta

Blocker

Home

Hospital

or

1 tab

12 hour
Both

Hypertension, angina pectoris and MI prevention.

Side effects/Nursing considerations Bradycardia, Heart failure, pulmonary edema, hypotension, hyperglycemia, hypoglycemia
Indication:

Name

pantoprazole (Protonix)

Route

INJ , IV push

40mg

Dosage Amount 10ml

Frequency once

Pharmaceutical class Proton

Indication

Concentration

pump inhibitor

Home

Hospital

daily

or

Both

Erosive esophagitis associated with gerd

Side effects/Nursing considerations

Name

sucralfate (Carafate

Route

Oral

Pseudomembranous colitis, hyperglycemia, bone fracture, hypomagnesaemia

Concentration

Dosage Amount 1

1gm

tab

Frequency every 4 hour

Home
Hospital
or
Both
GI Protectants
Short term management of duodenal ulcers, maintenance and prevention of duodenal ulcers

Pharmaceutical class
Indication

Side effects/Nursing considerations:

Name

Anaphylaxis , hyperglycemia, pruritus , rashes, constipation, nausea, diarrhea.

Electrolyte Replacement

Concentration

Route
Pharmaceutical class
Indication Bring electrolyte within
Side effects/Nursing considerations
Name

Frequency

PRN

Hospital

or

Home

hydrALAZINE

Dosage Amount

1 each

Dosage Amount

0.5 ml

Dosage Amount

1 tab

Both

normal range.

Concentration

10mg

INJ , IV push
Home
Vasodilators
Indication Moderate to severe hypertension (with diuretic)
Route

Pharmaceutical class

Frequency

PRN

Hospital

or

Both

Side effects/Nursing considerations

Name

nitroglycerin (Nitro-time)

Concentration

0.4 mg

Route Sublingual

PRN

or
Both
Nitrates
Adjunct treatment for Heart failure, acute myocardial I nfarction, management of angina pectoris.

Pharmaceutical class
Indication

Frequency
Home

Hospital

University of South Florida College of Nursing Revision August 2013

Side effects/Nursing considerations

Name

blurred vision, hypotension, abdominal pain, N/V, tachycardia, syncope.

ondansertron (Zofran)

Concentration

4mg

Dosage Amount

2ml

INJ, IV push
Frequency PRN
Home
Hospital
or
Both
Pharmaceutical class five ht3 antagonist.
Indication Prevent nausea and vomiting , treat postoperative nausea and vomting.
Route

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?
NPO
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? REGULAR
Consider co-morbidities and cultural considerations):
24 HR average home diet:
According to choose my plate the patient consume 2124
calories 258 of which were empty calorie this is 124
calorie
Breakfast: 1 cup plain oatmeal with 1 slice French toast
Greater than the required amount. The required grains
were
1 cup orange juice
6 oz. the patient had 7 oz., vegetable requirement was
Lunch: Ham lettuce cheese , tomato & mayonnaise
2 cups the patient had 2 cups, fruit juice requirement
sandwich.
was 2 cups the patient had 1 cup. Dairy was also low the
patient
had 2 cups and 3 cups were required , the patient
Dinner: 2 fried drum sticks with 1 cup mashed potato Consumed excessive protein 9 oz. only 5 oz. was
required.
Snacks: cashew nuts
Liquids (include alcohol): 2 16 oz. bottles water
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? The patient stated that his children assist him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
The patient states that he tries not to think about situation that may cause him to stress, he engages in more work.
He also stated that he talks through his problems when he is upset, it make him a bit calmer.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient States Mom being ill really stressed me out , that when I had my heart attact.

+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? ______________________Yes_____________________________
Have you ever been talked down to?___Yes_ _____ Have you ever been hit punched or slapped? ____Yes____

University of South Florida College of Nursing Revision August 2013

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______Yes Emotionally______________ If yes, have you sought help for this? _____Yes________
Are you currently in a safe relationship? The patient is currently single

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:

According to Berk, Self-absorption/stagnation entails the need for adults to create or nurture things that will
outlast them, often by having children or creating a positive change that benefits other people. Success leads to
feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient is in the self-absorption/stagnation phase of psychosocial development. The patient states I have
chosen to be single since my divorce because I need to understand who I am with just me. I know who I am as a
married man I know who I am as a father but, I have forgotten who I am without all of that , and I really want to
know.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I do believe that the disease has impacted my patients psychological stage of development because he is still
interested in learning about himself and in somewhat of a different way , he approaches his illness with urgency
and tries to get all aspect of his illness in order so he can get back to work. He states I want to have every test that
I need to get done, done while am here because I want to have adequate time to recuperate and get back to work

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? The patient states that his disease might be caused by stress from
his divorce , his brother recent passing and his mothers illness.
What does your illness mean to you? Patient stated its just natural sickness

+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?__________________N/A___ ________________________
Have you or your partner received the Gardasil (HPV) vaccination? __________N/A_________________________
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? ______N/A______________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
N/A

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?

The patient states that spirituality is very important to me I believe in the Lord Jesus Christ
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
_The patient believes that his religious belief has no influence on his illness, states I am just naturally ill
______________________________________________________________________________________________________

+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? Cigars
How much?(specify daily amount)
1 cigar every other day

Yes
No
For how many years? X years
(age 52
thru 53 )
If applicable, when did the
patient quit?

Pack Years: N/A

Does anyone in the patients household smoke tobacco? If
so, what, and how much? NO

Has the patient ever tried to quit? NO

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Wine, Hennessey
How much? (give specific volume)
2 glass wine per week
2 drink od Hennessey 4oz per week
If applicable, when did the patient quit?

For how many years?

(age 51
thru 53
)

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?
Just tried it
(age 51 thru 51 )
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

Just tried it once

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Yes my maintenance job does entail chemical exposure

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain -10lbs

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
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:

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
Abdominal Abscess
Last colonoscopy?
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
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
x/day
x/year

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?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
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
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No the patient has no prior health problems that he sought care for.

Any other questions or comments that your patient would like you to know?
The patient wanted to know more about nutrition that is best for people with heart problems and also more
information about his medications.

University of South Florida College of Nursing Revision August 2013

10

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

General Survey:
Temperature: (route taken?)
Oral 36.8

Height: 57
Pulse:57
Respirations: 18

Weight: 180
Blood 137/87
Pressure:

BMI: 28.2

Pain: (include rating & location)

Has no pain

(include location)

SpO2 100%
Is the patient on Room Air or O2: 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
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
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

talkative
withdrawn

quiet
boisterous
aggressive
hostile

flat
loud

Peripheral IV site Type:

Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
Patient does not have any lines going
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 / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right earinches & left earinches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Patients teeth are intact no dentures
Comments

University of South Florida College of Nursing Revision August 2013

11

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

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space mid clavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

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: 2+
Popliteal: 2+
DP: 2+
PT: 2+
No temporal or carotid bruits
Edema: No edema
[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

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:
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 09 / 23 / 2014 )
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 __5___ RUE __5___ LUE ___5__ RLE

& __5____ 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

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: +2

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):
The patient has a colonoscopy and endoscopy (EGD ) scheduled . The colonoscopy will allow the provider
to visualize any bleeding in the lower gastrointestinal tract and the endoscopy will allow visualization of
bleeding in the upper intestinal tracts.
Lab
WBC 5.6k/mcl

Dates
Trend
09/23/201 Upon admit, the patients WBC
4
count were in normal

Analysis
Normal WBC is an indication that
there is no infection process going on.

RBC 4.49mi1

9/23/2014 Upon admission the patients

RBC count were a bit low

Hgb 15.8 gm/dl

9/23/2014 Upon admission the patients

Hgb were normal.

Low RBC count could suggest

Anemia but I dont think this patient
RBC count is low enough to suggest
that, it could also suggest a problem
with production or loss of blood.
Normal Hgb suggest the blood O2
carrying capability is intact.

Hct 44.0%

9/23/2014 Hct is within normal range

upon admission

Glucose 81mg/dl

9/23/2014 The patient has normal blood

sugar reading

BUN 13 mg/dl

9/23/2014 The patient BUN is within

normal limits.

Creatinine 0.9mg/dl

9/23/2014

Sodium 139 meq/L

9/23/2014

Potassium 3.9 meq/L

9/23/2014

The patient creatinine is

within normal range
The patients sodium is
normal
The patients potassium are
within normal limits

Normal Hct suggest that there are

normal number of RBC in a volume
of blood
Normal blood sugar indicates that the
patient is not diabetic nor pre
disposed to diabetes.
A normal BUN indicates that the
kidneys and liver are functioning
normally.
Normal creatinine suggests the
kidneys are working well.
Normal sodium meants that there are
normal amount of sodium in the blood
(kidney are filtrating fine)
Normal potassium means that there is
adequate amount of potassium in the
blood stream

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently NPO, this is because he is awaiting a diagnostic test/surgery. His vitals are
schedule for every 4 hours this is due to his MI and HTN it is important to keep track of his vitals. The
patient is able to ambulate on his own and is encouraged to take walks to prevent clot formation and bed
sores. The patient does not have scheduled accu checks. He is schedule for a colonoscopy and endoscopy to
visualize what is causing him to have blood in his stools. The patient has a cardiologist consult as we need
to know it his heart can handle the procedure.

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

1. Deficient fluid volume related to bleeding as evidence by blood in stool
2. Nutrition imbalance more than body requirement, related to high calorie intake as evidence by 28.1 BMI.
3. Anxiety related to knowledge deficit of the disease process as evidence by questions asked about his condition
anxiousness and talkativeness.
4.
5.

 15 CARE PLAN
Nursing Diagnosis: (Deficient fluid volume related to bleeding as evidence by blood in stool)
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Absence of hematemesis and Assess for and report signs and
If the patient is experiencing
Melena remained absent in the
melena.
symptoms of bleeding esophageal
hematemesis or melena is crucial patients stool and emesis.
varices (e.g. hematemesis; melena;
that is caught early as this could
decreased B/P; increased pulse;
lead hypovolemia (Elsevier 2012)
decreasing RBC, Hct, and Hb levels).
Blood Pressure and pulse
Monitor vital signs; compared with
It is important to know the
Patient pulse was a bit low 57 and
will remain within normal
normal results of client / previous.
patients vital signs at all times, a his blood pressure was a just a little
range for client.
Measure blood pressure with sitting, change in vitals could mean the
high 137/87.
sleeping, standing if possible.
patient is getting better or getting
worst, Postural hypotension
showed decreased circulating
volume (Elsevier 2012)
Fluid requirements are met.
Record the individual patient's
Worsening of symptoms may
Patient remained hydrated and had
physiological response to bleeding,
indicate the continued bleeding
no abnormal complaints .
such as mental changes, weakness,
or inadequate fluid replacement
restlessness, anxiety, pale, sweaty,
(Elsevier 2012)
tachypnea, the increase in
temperature.
Patient Goals/Outcomes

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

 15 CARE PLAN
Nursing Diagnosis: (Nutrition imbalance more than body requirement, related to high calorie intake as evidence by 28.1 BMI. )
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
Patient verbalizes
Document weight; do not
Patients may be unaware of their actual Patient verbalized that he needs to
measures necessary to
estimate.
weight.
change his diet
achieve weight reduction
Determine body fat composition Skin calipers can be used to estimate
of skinfold measurement.
amount of fat (Elsevier 2012)
Patient demonstrates
Perform a nutritional
This should include types and amount of Patient is not really sure what foods
appropriate selection of
assessment
foods eaten, how food is prepared, the
are right for him.
meals or menu planning
Assess ability to plan a menu,
pattern of intake (time of day,
Dietician consults necessary.
toward the goal of weight
making appropriate food
frequency, and other activities patient is
reduction.
selections.
engaged in while eating) (Elsevier 2012
Patient begins an
Assess effects or complications of Medical complications include
Patient is still in the hospital but
appropriate program of
being overweight.
cardiovascular and respiratory
verbalized that he will be more
exercise.
Assess usual level of activity
dysfunction, higher incidence of
active
diabetes mellitus, and aggravation of
musculoskeletal disorders. Social
complications and poor self-esteem may
also result from obesity.
Patients may confuse routine activity
with exercise necessary to enhance and
maintain weight loss (Elsevier 2012)
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

 15 CARE PLAN
Nursing Diagnosis: (Anxiety related to knowledge deficit of the disease process as evidence by questions asked about his condition anxiousness and
talkativeness.)

Patient
Goals/Outcomes

Nursing Interventions to Achieve

Goal

Rationale for Interventions

Provide References

Evaluation of
Interventions on Day
care is Provided
Patient is able to
verbalize signs of
anxiety

Patient is able to
recognize signs of
anxiety.

Assess patient's level of anxiety

and acknowledge awareness of
patient's anxiety.

This can be done by interviewing the patient. This

assessment helps determine the effectiveness of coping
strategies currently used by patient. Since a cause for
anxiety cannot always be identified, the patient may feel
as though the feelings they are experiencing are
counterfeit. Acknowledgment of the patient's feelings
validates the feelings and communicates acceptance of
those feelings (Elsevier 2012)

Patient
demonstrates
positive coping
mechanisms.

Encourage patient to seek

assistance from an understanding
significant other or from the
health care provider when anxious
feelings become difficult.
Assist the patient in developing
anxiety-reducing skills (relaxation,
deep breathing, positive
visualization, reassuring selfstatements, and others)

The presence of significant others reinforces feelings of

security for the patient (Elsevier 2012)

Patient is able to talk

about his problems and
find it makes him feel
better and less nervous

Using anxiety-reduction strategies enhances patient's

sense of personal mastery and confidence (Elsevier 2012)

I was not able to reevaluate the patients

level of anxiousness as
the patient was
sleeping.

Patient may
describe a
reduction in the
level of anxiety
experienced.

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

References
Elsevier. (2012). Nursing diagnosis care plans. Anxiety. Retrieved October 5, 2014, from
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick04.html.
Elsevier. (2012). Nursing diagnosis care plans. Nutrition Altered. Retrieved October 5, 2014, from
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick37.html.
Huether, E.S. & McCance, L.K. (2012) Understanding Pathophysiology: Myocardial Infarction.
(5th Ed). St Louis Missouri, USA. Loren S. Wilson.
Laura E. Berk. (2010). Exploring lifespan development: Stages of development. (2nd Ed). Boston MA ,USA.
Pearson.
United States Department Of Agriculture. ( 2013, September 30). Super Tracker: Food Tracker. Retrieved
October 2, 2014, from https://www.supertracker.usda.gov/foodtracker.aspx.
Maziar, Zafari. (2010, March 18). Prognosis. Myocardial Infarction. Retrieved October 5, 2014, from
http://emedicine.medscape.com/article/155919-overview#aw2aab6b2b7aa.