UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Lindsey Willis

PATIENT ASSESSMENT TOOL .

Assignment Date: 10/4/15

Agency: TGH

1 PATIENT INFORMATION
Patient Initials: B.K.

Age: 59 y.o.

Admission Date: 9/18/15

Gender: Female

Marital Status: Divorced

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Coronary Artery Disease (CAD) 125.10

Level of Education: A. A. in Business Management

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): retired truck driver

Abnormal Stress Test 786.09

Number/ages children/siblings:

Dyspnea 794.39

4 children/35, 33, 33, 29/siblings

Served/Veteran: N/A

Code Status: Full Code

Living Arrangements: Divorced. Living with significant other for

the past 6 years.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 9/19/15 Procedure: cardiac
catheterization

Culture/ Ethnicity /Nationality: German, French, and English

ancestry
Religion: Christian

Type of Insurance: Hillsborough County Insurance

1 CHIEF COMPLAINT:
Heart issues. I had a stress done Friday and was told to go to the hospital immediately.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
59 y.o. female with past medical history of diabetes mellitus, hypertension. Sent to the ER from her cardiologists office
that the patient had a stress test done showing that it was abnormal; so the patient was sent to the ER for further
evaluation. The patient denies any chest pain, but presented with dyspnea. No fever or chills, nausea, vomiting, headache.
OLDCARTS: Dyspnea. Onset: 9/19/15; Location: lungs/chest. Duration: 12-24 hours. Characteristics: shortness of breath.
Aggravating factors: exertion. Relieving factors: rest and oxygen administration. Treatment: oxygen. Severity: moderate
to severe difficulty in breathing.

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

Operation or Illness
Thoracic Outlet Syndrome
Diabetes Mellitus
Hypertension
Hyperlipidemia
Anxiety and depression
Incontinence Surgery

University of South Florida College of Nursing Revision August 2013

Age (in years)

5
0
7
9

Father
Mother

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Hypertension
Problems
Kidney

Gout
Heart Trouble
(angina, MI, DVT etc.)

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Anemia
Arthritis

Cause
of
Death
(if
applicab
le)

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Hysterectomy

Alcoholism

Unknown Date

CAD
Ovarian
cancer

Brother
5
6

Sister
relationship
relationship
relationship

Comments: Patient did not know age of onset for family medical history

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) Unknown
Adult Tetanus (Date) 2015
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
Other (food, tape,
latex, dye, etc.)

NAME of
Causative Agent

YES

NO

Type of Reaction (describe explicitly)

No known allergies
No known allergies

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)
Coronary artery disease (CAD) is part of a continuum of conditions affecting the coronary arteries, such as arteriosclerosis
and atherosclerosis. These conditions result in decreased oxygen and nutrients to the myocardium. The most common
cause of reduced myocardial blood flow is atherosclerosis (Osborn, Wraa, Watson, & Holleran, 2014, pp. 920).
Atherosclerosis is a type of arteriosclerosis that results in coronary artery luminal obstruction due to plaque buildup
infiltrating the lining of the arterial wall, which leads to a reduction of blood flow to the myocardium (Osborn et al.,

University of South Florida College of Nursing Revision August 2013

2014, pp. 920). A reduction in myocardial blood supply can lead to a variety of coronary syndromes: stable angina,
unstable angina, acute myocardial infarction, and sudden cardiac death (Osborn et al., 2014, pp. 920). These syndromes
represent a sequence of progressively worsening diseases, due to the increasing imbalance between myocardial oxygen
demand and oxygenated blood supply. To meet the myocardial oxygen demand, myocardial blood flow must be increased.
With CAD the arteries do not dilate properly, or at all, due to the plaque buildup and calcification within the artery walls
(Osborn et al., 2014, pp. 920). Additionally, due to decreased blood supply, the heart muscle has significant difficulty
increasing the force of contraction to increase cardiac output (Osborn et al., 2014, pp. 920). Overall the unmet oxygen
demand, leads to myocardial ischemia resulting in angina (Osborn et al., 2014, pp. 920). Risk factors for CAD are both
non-modifiable and modifiable. Non-modifiable risk factors include age, gender, and genetic predisposition. Genetics and
age, especially for women after menopause, are significant factors in the development of CAD. Modifiable risk factors
include metabolic syndrome, smoking, diabetes, sedentary lifestyle, and poor diet. Modifying these factors can lead to a
significant decrease in the potential to develop CAD (Huether & McCance, 2012, pp. 597-598). Evaluation and diagnosis
of CAD can be done through a variety of tests: stress testing, radionuclide imaging, positron-emission tomography or a
PET scan, multi-slice helical CT, multi-gated acquisition scan, cardiac MRI, intravascular ultrasound, cardiac
catheterization, and percutaneous coronary intervention (PCI) (Osborn et al., 2014, pp. 937). Diagnosis is also based on a
review of systems, and the patients medical/social/family history for associated diseases and risk factors (Osborn et al.,
2014, pp. 945). There is no cure for CAD but there is medical management for the disease through the use of
pharmaceuticals and lifestyle modification. Pharmaceutical management includes a variety of medications: beta-blockers,
ACE inhibitors, ARBS, vasodilators, thrombolytic agents, anticoagulants, and nitrates. When the arteries become severely
occlude a coronary artery bypass graph (CABG) may be performed. A CABG uses healthy arteries to bypass diseased
segments within the heart. CAD is a progressive disease and will lead to myocardial infarction and eventual heart failure
(Osborn et al., 2014, pp. 964-965).

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

(amitriptyline)

Concentration (mg/ml)

Route: Oral

Dosage Amount (mg): 200mg

Frequency: Nightly

Pharmaceutical class: Tricyclic

Home
Hospital
or
Both
antidepressants
Indication: Management of depression.
Side effects/Nursing considerations: Suicidal thoughts, arrhythmias, torsade de pointes, sedation, hypotension, constipation,
blurred vision. Monitor for suicidal tendencies, frequent ECG monitoring for patients taking high doses or a history
of cardiovascular disease.
Name: Aspirin

Concentration

EC

Dosage Amount: 81mg

Route: Oral

Frequency: Daily

Pharmaceutical class: Salicylates

Home

Hospital

or

Both

Indication: Prophylaxis

od transient ischemic attacks and MI.

bleeding, laryngeal edema, anaphylaxis, dyspepsia, hepatoxicity, tinnitus. Monitor
hepatic function, for signs of toxicity overdose. Teach patient of increased risk for bleeding.
Side effects/Nursing considerations: GI

Name: Lipitor

(atorvastatin)

Concentration

Dosage Amount: 40mg

Route: Oral

Frequency: Nightly

Pharmaceutical class: HMG-CoA reductase

Home
Hospital
or
Both
inhibitors
Indication: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia. Primary prevention of
coronary artery disease.
Side effects/Nursing considerations: Rhabdomyolysis, angioneurotic edema, abdominal cramps, constipation, diarrhea, flatus,
dyspepsia. Monitor hepatic function. Instruct patient to notify a health care professional if unexplained muscle pain,
tenderness, or weakness occurs, especially accompanied by fever or malaise.
Concentration
Name: Dulcolax (colace)
Dosage Amount: 100mg
Route: Oral

Frequency: Twice

Pharmaceutical class: Stool

softeners

Home

Hospital

or

daily

Both

University of South Florida College of Nursing Revision August 2013

Indication: Prevention

of constipation.
Side effects/Nursing considerations: Mild cramps, diarrhea. Assess for abdominal distention, presence of bowel sounds, and
usual pattern of bowel function. Teach patients that laxatives should be used only for short-term therapy.
Name: Lovenox

(enoxaparin)

Concentration: 40mg/ml

Route: subcutaneous

Dosage Amount: 40mg

Frequency: Daily

Pharmaceutical class: Anti-thrombotics,

low molecular

Home

Hospital

or

Both

weight heparin
Indication: Prevention of venous thromboembolism (VTE).
Side effects/Nursing considerations: Bleeding, anemia, hyperkalemia, edema, dizziness, headache. Monitor for signs of
bleeding.
Name: Pepcid

Concentration

(famotidine)

Dosage Amount: 20mg

Route: Oral

Frequency: Twice daily

Home
Hospital
or
Both
h2 antagonists
Indication: Prevention and treatment of stress-induced upper GI bleeding in critically ill patients.
Side effects/Nursing considerations: Arrhythmias, agranulocytosis, aplastic anemia, confusion. Monitor for epigastric or
abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.
Pharmaceutical class: Histamine

Name: Zestril

Concentration

(lisinopril)

Dosage Amount: 40mg

Route: Oral

Frequency: Daily
Home
Hospital
or
Both
inhibitors
Indication: Alone or with other agents in the management of hypertension. Reduction of risk of death or development
of heart failure after myocardial infarction.
Side effects/Nursing considerations: Angioedema, cough, dizziness, hypotension, hyperkalemia. Monitor BP and pulse.
Monitor weight and assess patient routinely for resolution of fluid overload. Monitor for signs of angioedema.
Pharmaceutical class: Ace

Name: Glucophage

(metformin)

Concentration

Dosage Amount: 1,000mg

Route: Oral

Frequency: Twice

Pharmaceutical class: Biguanides

Home

Hospital

or

daily

Both

Indication: Management

of type 2 diabetes mellitus.

acidosis, abdominal bleeding, diarrhea, nausea, vomiting. Patients who have been
well controlled on metformin who develop illness or laboratory abnormalities should be assessed for ketoacidosis or
lactic acidosis. Explain to patients that metformin helps control hyperglycemia but does not cure diabetes.
Side effects/Nursing considerations: Lactic

Name: Paxil

(paroxetine hydrochloride)

Concentration

Dosage Amount: 20mg

Route: Oral

Frequency: Daily

Pharmaceutical class: Selective

serotonin reuptake

Home

Hospital

or

Both

inhibitors
Indication: Major depressive disorder, panic disorder, generalized anxiety disorder.
Side effects/Nursing considerations: Neuroleptic malignant syndrome, suicidal thoughts, Stevens-Johnson syndrome, anxiety,
dizziness, drowsiness, insomnia, weakness, dry mouth. Monitor for serotonin syndrome, neuroleptic malignant
syndrome, and rash. Assess for suicidal tendencies.

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:
Diet pt follows at home? Regular
My patients diet was high in saturated fat, oils, and
sodium. In comparison with an average 2,000 calorie diet,
my patient was over her daily allowance by 200 calories.
The recommended daily allowance for grains is 6oz, and
my patient had consumed 0oz. Healthy examples of wholewheat grains include oatmeal, whole cornmeal, and brown
rice. The recommended daily allowance of vegetables is 2.5
cups, and my patient had consumed 5 cups. Most
vegetables are low in fat and calories, and most any type
can be eaten to reach your recommended daily value. It is
important to incorporate a variety of vegetables into your
diet: dark-green vegetables, starchy vegetables, red and
orange vegetables, and beans and peas. The recommended
daily allowance of fruits is 2 cups, and my patient had
consumed 0 cups. Like vegetables, most any type can be
eaten to reach your recommended daily value, but it is
important to avoid fruits in sugary syrups and juices. The
recommended daily allowance of dairy is 3 cups, and my
patient consumed 1.75 cups. Healthy examples of dairy
include fat-free or low-fat milk, yogurt, and cheese. The
recommended daily allowance of protein is 5.5oz, and my
patient consumed 8oz. Healthy examples of protein include
lean or low-fat meat, poultry, or fish rich in omega-3 fatty
acids. The recommended daily allowance of oils, saturated
fats, and sodium are 6tsp, 22g, and 2,300mg, respectively.
My patient consumed 7tsp of oil, 50g of saturated fats, and
4,29mg of sodium.
24 HR average home diet:
Breakfast: Bacon and eggs
Lunch: Does not eat lunch
Dinner: Pot roast with potatoes and steamed vegetables
Snacks: Cheese sticks, ice cream, crackers/chips
Liquids (include alcohol): Water (3 16oz. bottles/day) and
diet Dr. Pepper (3 12oz. cans/day)

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
University of South Florida College of Nursing Revision August 2013

discussion)
Who helps you when you are ill?
My significant other.
How do you generally cope with stress? or What do you do when you are upset?
Rest and relax, play computer games, watch TV, listen to music.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Increased anxiety and depression.

+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? _____N/A______________
Are you currently in a safe relationship? Yes

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

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 stage 7: generativity vs. stagnation. The goal of this stage is to be creative and productive. Often this is
accomplished through work or relationships, such as raising healthy, functional children or contributing to society by
developing a distinguished career, for example in nursing. The person who fails to achieve generativity (the desire and
motivation to guide the next generation) may manifest stagnation in the form of superficial relationships and selfabsorption (Treas & Wilkinson, 2014, pp. 164).
I believe my patient has achieved generativity through a fulfilling career as a truck driver which she loved and is now
retired from and raising her 4 children. She also has had a long-term relationship for the past 6 years, which has given
her love and support.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life:
I believe my patients illness has had a significant effect on her life and her ability to enjoy her life as a retired adult. I
believe she may have developed a sense of stagnation as evidenced by her increased depression and anxiety in
conjunction with her progressively worsening condition. She is no longer to participate in activities that bring her
enjoyment or spend time with family and friends.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Genetics

University of South Florida College of Nursing Revision August 2013

What does your illness mean to you?

Crippling and debilitating. I cant do what I want.

+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? ___Men_____________________________________________________
Are you aware of ever having a sexually transmitted infection? __No__________________________________________
Have you or a partner ever had an abnormal pap smear?___No_______________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No_____________________________________
Are you currently sexually active? ___Yes___________________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? __in a monogamous relationship, patient
had a hysterectomy___________________
How long have you been with your current partner?____6 years_____________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ___No____________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
I believe in God, but I dont go to church regularly.
__________________________________________________________________________________________
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?
How much?(specify daily amount)
Cigarettes
1 pack per day

Does anyone in the patients household smoke tobacco? If

so, what, and how much? No

thru

56

Has the patient ever tried to quit? Yes

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Beer, wine, kahlua and cream

(age 14

If applicable, when did the

patient quit? 2012

Pack Years: 46 years

What?

Yes
No
For how many years? 42 years

Yes

No

How much? (give specific volume)

For how many years? 15-20

years

Socially, 1x/month, 2-3 drinks

(age 20s

thru

30s

If applicable, when did the patient quit?

20-25 years ago
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much? 0.25 oz./ weeks
For how many years? 37 years
(age

Is the patient currently using these drugs?

Yes No

22

thru

current

If not, when did he/she quit?

Off and on over the years, but
currently using

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

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution

Gastrointestinal

Recent weight loss or gain

Nausea, vomiting, or diarrhea

Constipation
Irritable
Bowel
GERD
Cholecystitis
Indigestion
Gastritis /
Ulcers
Hemorrhoids
Blood in
the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis

Integumentary

Changes in appearance of skin

Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen: No

SPF:

Bathing routine: 2-3 times/week

Other:

Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

HEENT

Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds

Genitourinary

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
10 x/day
Bladder or kidney infections

Post-nasal drip
Oral/pharyngeal infection
Dental problems

Immunologic

Chills with severe shaking

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

Other:
Hematologic/Oncologic

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
Metabolic/Endocrine

Routine brushing of teeth

2 x/day

Routine dentist visits

x/year

Diabetes

Type: 2

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Vision screening

Other:
Pulmonary

Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis

irregular

Environmental allergies
last CXR? 9/19/15
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? 1992
menstrual cycle
regular
menarche
age? 13
menopause
age? 50-52
Date of last Mammogram &Result:
2015

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

University of South Florida College of Nursing Revision August 2013

Cardiovascular

Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
9/19/15
Other:

Date of DEXA Bone Density &

MEN ONLY
Infection of male
genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

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:

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.

University of South Florida College of Nursing Revision August 2013

10

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

General Survey: %9 y.o. pt has Height: 175.3 cm
Weight: 110.6 kg BMI:
Pain: (include rating & location)
no visible signs of distress,
5, right wrist
Pulse: 80
Blood
alert and oriented x3.
Pressure: 120/71, left arm
(include location)
Temperature: (route taken?)
Respirations: 18
98.3F, oral
SpO2: 99%
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: 22 gauge

Location: right median cubital vein Date inserted: 9/21/15
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
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 ear- 6
inches & left ear- 6
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: PERRLA test unable to perform

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: S5, 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)
Unable to get ECG strip

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: +3 Carotid: +3 Brachial: N/A Radial: +3 Femoral: N/A Popliteal: N/A DP: +3
PT: N/A
No temporal or carotid bruits
Edema: 0
[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: yellow
Previous 24 hour output: 900 mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 9 / 20 / 2015
)
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 paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

Equipment unavailable to test CNs, Rombergs test, stereognosis, graphesthesia, proprioception, and DTR

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
WBC:
9.53
7.65
Normal: 4.6-10.2

Dates
9/19/15
9/22/15

Hemoglobin:
13.0
14.0
Normal: 12.2-16.2

9/19/15
9/22/15

Platelets:
302.0
260.0
Normal: 142.0-424.0

9/19/15
9/22/15

Trend
Upon admittance, the
patients WBCs were
slightly elevated but
within normal range.
WBCs were trending
down but within normal
range.

The patients hemoglobin

slightly increased
throughout her hospital
stay but remained within
normal range on the
lower end of the scale.

The patients platelet

count trended downward
throughout her hospital
stay but remained within
normal range. This was

Analysis
WBCs exit in the blood
and help fight infection
within the body. Elevated
WBC levels is referred to
as leukocytosis and is a
response from the
immune system due to
infection or disease.
Decreased WBC levels is
referred to as leukopenia.
Leukopenia may be
caused by bone marrow
damage or disorders,
autoimmune disorders, or
diseases of the immune
system.
Hemoglobin is the ironcontaining protein in
RBCs, that allow them to
bind oxygen and carry it
throughout the body.
Hemoglobin levels may
be elevated due to
pulmonary disease,
congenital heart disease,
smoking, and
dehydration. Hemoglobin
levels may be decreased
due to excessive blood
loss, iron deficiency, bone
marrow disorders, or
kidney disease.
Platelets are fragments of
cells essential for normal
blood clotting. An
elevated platelet count is
referred to as

most likely due to the

administration of
Lovenox.

Hematocrit:
39.4
42.7
Normal: 37.7-47

9/19/15
9/22/15

Na+:
141.0
139.0
Normal: 135.0-148.0

9/19/15
9/22/15

K+:
4.0
4.2
Normal: 3.5-5.3

9/19/15
9/22/15

Cl-:
105.0
104.0

9/19/15
9/22/15

Upon admittance, the

patients hematocrit level
was on the low end of the
scale but within normal
limits. Throughout her
hospital stay, her
hematocrit trended
upward.
The patients sodium
level remained within
normal limits throughout
her hospital stay but did
slightly decrease.

The patients potassium

levels trended slightly
upward throughout her
hospital stay but
remained within normal
limits.

The patients chloride

levels were on the high
end of the scale

thrombocytosis and is
most often the result of an
existing condition. A
decreased platelet count is
referred to as
thrombocytopenia and is
most often caused by
bone marrow disorders
causing decreasing
production or conditions
where they are used up
faster than normal. For
example, heparin-induced
thrombocytopenia.
Hematocrit levels are
often used to test for
anemia, polycythemia,
hydration status, and to
monitor therapy. Elevated
hematocrit levels are
often a sign of
polycythemia. Decreased
hematocrit levels often
indicate anemia.
Sodium is an extracellular
cation, that is tested to
evaluate electrolyte
balance and hydration
levels. Hypernatremia is
most often due to
inadequate water intake
and dehydration.
Hyponatremia typically
due to excess sodium
loss, excess water intake
or retention, or edema.
Potassium is an
intracellular cation, that is
tested to evaluate fluid
and electrolyte balance.
Hyperkalemia is most
commonly due to kidney
disease. Hypokalemia
often occurs due to
electrolyte imbalance
from vomiting and
diarrhea.
Chloride is the most
abundant anion in the
extracellular fluid.

Normal: 98.0-107

throughout her hospital

stay but remained within
normal limits.

HCO2:
22.0
27.0
Normal: 22.0-29.0

9/19/15
9/22/15

BUN:
19.0
22.0 H
Normal: 6.0-20.0

Creatinine:
0.9
0.9
Normal: 0.57-1.11

9/19/15
9/22/15

9/19/15
9/22/15

Upon admittance, the

patients HCO2 level was
on the low end of the
scale but within normal
limits. The HCO2 level
trended upward
throughout her hospital
stay.

Upon admittance, the

patients BUN level was
elevated but still within
normal range. The BUN
level continued to trend
upward and was elevated.
This was most likely due
to recent her recent
ischemic event/stress to
the heart.

The patients creatinine

levels remained the same
throughout her hospital
stay.

Chloride is tested to
evaluate electrolytes,
acid-base balance, and
hydration level.
Hyperchloremia typically
indicates dehydration.
Hypochloremia typically
occurs with disorders that
cause low sodium levels.
Bicarbonate is tested as
part of the electrolyte
panel to detect, monitor,
and evaluate electrolyte
imbalance. When
bicarbonate levels are
high or low, it indicates
the body is having trouble
maintaining acid-base
balance or something has
upset the electrolyte
imbalance. For example,
losing too much or
retaining too much fluid.
The blood urea nitrogen
test (BUN) is used to
measure kidney function.
Urea is a waste product
from the liver that results
from protein metabolism.
Urea travels in the blood
to the kidneys, where it is
filtered out of the blood
and eliminated in the
urine. BUN levels elevate
when there is disease or
damage to the kidneys.
Low BUN levels are less
common and are of
serious concern.
The creatinine test is used
to measure kidney
function. Creatinine is a
waste produced by
muscles from the
breakdown of creatine.
Creatinine travels in the
blood to the kidneys,
where it is filtered out of
the blood and eliminated
in the urine. Creatinine

levels elevate due to

kidney disease or
conditions affecting
kidney function. Low
creatinine levels are less
common and are of
serious concern.
Troponin I:
Upon admittance, the
Troponin I is a protein
0.010
9/19/15 00:19
patients troponin I level
found specifically in
<0.010
9/19/15 06:06
was slightly elevated.
cardiac muscle. Elevated
Normal: 0.000-0.032
This is due to the
troponin levels indicate
ischemic event/stress to
damage to the heart has
the heart that occurred.
occurred. Troponin levels
are typically elevated
after a recent myocardial
infarction.
9/19/15: Chest X-ray: no comparison. Used to evaluate heart size, identify congestion or effusions. Cardiac
silhouette, lungs clear, no evidence of pleural effusion, no gross pneumothorax identified. Bony structures of the
chest unremarkable.
9/19/15: 12-lead ECG: no comparison. Used to identify electrical abnormalities of the heart. Sinus rhythm with
occasional ventricular premature complexes, left ventricular hypertrophy, and S-T change.
9/19/15: Transthoracic Echocardiogram: no comparison. Used to measure the cardiac chambers, evaluate
structural abnormalities, and identify valvular vegetation and pressure gradients. Left ventricle: normal cavity
size and wall thickness, ejection fraction was in the range of 35-40%. Aortic valve: moderate regurgitation. Left
atrium: normal size. Right ventricle: normal cavity size and wall thickness, normal systolic function. Right
atrium: normal size. Pulmonary arteries: systolic pressure was within normal range.
9/20/15: Left heart catheterization: no comparison. Used to confirm the patency of the coronary arteries,
determine blood flood in the chambers and great vessels of the heart, and evaluate pressure across valves,
identifies areas of plaque buildup. Results were pending. I would expect to see coronary artery stenosis, valve
damage, and decreased ventricular function based on the patients diagnosis and other diagnostic tests performed.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
1.) CAD: ECHO, cardiac catheterization, aspirin, atorvastatin: ECHO: used to measure the cardiac chambers,
evaluate structural abnormalities, and identify valvular vegetation and pressure gradients. Cardiac
catheterization: used to confirm the patency of the coronary arteries, determine blood flood in the
chambers and great vessels of the heart, and evaluate pressure across valves, identifies areas of plaque
buildup. Aspirin: pharmaceutical prophylactic treatment of thrombus formation via decreasing platelet
aggregation. Atorvastatin: pharmaceutical prophylactic treatment of myocardial infarction and stroke via
reduction of lipids/cholesterol and slows progression of coronary atherosclerosis.
2.) Hypertension: lisinopril. Pharmaceutical management of hypertension. Given daily.
3.) Anxiety and depression: Paxil. Pharmaceutical management of anxiety and depression. Given daily.
4.) Diabetes mellitus: sliding scale insulin and metformin. Pharmaceutical management of type 2 diabetes.
Given daily.
5.) Prophylaxis: Pepcid (twice daily) and Lovenox (daily). Pepcid: pharmaceutical prophylactic treatment of
stress-induced upper GI bleeding or stress ulceration. Lovenox: pharmaceutical prophylactic treatment of
venous thromboembolism and ischemic complications.

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

1. Decreased cardiac output r/t cardiac dysfunction AEB dyspnea, S-T segment change, elevated troponin levels, and
low LVEF
2. Acute pain r/t myocardial ischemia AEB patient states pain, dyspnea, and anxiety
3. Activity intolerance r/t decreased cardiac output AEB dyspnea with exertion and ECG changes

 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t cardiac dysfunction AEB dyspnea, S-T segment change, elevated troponin levels, and low LVEF
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
Patient will demonstrate adequate *Monitor for and report signs and
These are signs and symptoms
Patient showed no signs or
cardiac output as evidenced by
symptoms of fluid volume
consistent with heart failure and
symptoms of fluid volume overload
blood pressure, pulse rate and
overload, including the following:
decreased cardiac output (Ackley at end of shift. She did have mild
rhythm within normal parameters
dyspnea at rest, paroxysmal
& Ladwig, 2014, pp. 180)
dyspnea upon exertion but not
for client; strong peripheral pulses; nocturnal dyspnea, abdominal
while at rest.
maintained level of mentation.
distention, weakness and fatigue,
Lack of chest discomfort or
JVD, crackles, laterally displace
dyspnea, and adequate urinary
PMI, irregular heart beat, and
output; an ability to tolerate
diminished pulses (Ackley &
activity without symptoms of
Ladwig, 2014, pp. 180).
dyspnea, syncope, or chest pain
(Ackley & Ladwig, 2014, pp. 179).
Administer oxygen as needed per Supplemental oxygen increases
Patient was able to remain on room
physicians order (Ackley &
oxygen availability to the
air throughout the shift without any
Ladwig, 2014, pp. 180).
myocardium (Ackley & Ladwig,
difficulty in breathing. Oxygen at
2014, pp. 180).
2L via nasal cannula was available
if needed.
*Place client in semi-Fowlers or
Elevating the head of the bed and Patient remained in a semihigh-Fowlers position with legs
legs in down position may decrease Fowlers position for the majority
down or in a position of comfort
the work of breathing and may also of the shift without any difficulty in
(Ackley & Ladwig, 2014, pp. 180). decrease venous return and
breathing. Patient was also able to
preload (Ackley & Ladwig, 2014, rest in a supine position with two
pp. 180).
pillows without difficulty in
breathing for a few hours.
Check blood pressure, pulse, and
It is important that the nurse
The patients vitals were taken and
condition before administering
evaluate how well the client is
assessed prior to all medication
cardiac medications such as ACE
tolerating current medications
administration. The patients blood
inhibitors, ARBS, digoxin, and
before administering cardiac
pressure and heart rate were within
beta-blockers. Notify physician if
medications; do not hold
normal range.
heart rate or blood pressure is low
medications without physician
before holding medications
input. The physician may decide to

(Ackley & Ladwig, 2014, pp. 181).

have medications administered

even though the blood pressure or
pulse rate has lowered. (Ackley &
Ladwig, 2014, pp. 181).
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
As this is a new diagnosis, it extremely important the patient follow-up with a cardiologist post-discharge. It is also import the patient is discharged
with the follow medications and taught how and when to take them: a beta-blocker, a calcium channel blocker, an ACE inhibitor and/or an ARB, a
statin, a diuretic, and aspirin.

 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t myocardial ischemia AEB patient states pain, dyspnea, and anxiety
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Patient will report decreased pain
*Administer analgesics as
Pharmacological interventions are
level of less than 4 out of 10 by end prescribed by physician (Ackley first-line approaches to the
of shift.
& Ladwig, 2014, pp. 581).
management of pain (Ackley &
Ladwig, 2014, pp. 581)

*Teach the patient how to take

sublingual nitroglycerin when
needed for chest pain and note its
side effects (Osborn, Wraa,
Watson, & Holleran, 2014, pp.
962).

This encourages the patient to

learn and participate in their own
care and teaches one of the most
important interventions for patients
with CAD (Osborn et al., 2014,
pp. 962).

Ask the client to describe prior

experiences with pain,
effectiveness of pain management
interventions, responses to
analgesic medications including
occurrence of side effects, and
concerns about pain and its
treatment and informational needs
(Ackley & Ladwig, 2014, pp. 577)

Obtaining an individualized pain

history helps to identify potential
factors that may influence the
clients willingness to report pain,
as well as factors that may
influence pain intensity, the clients
response to pain, anxiety, and
pharmacokinetics of analgesics.
Pain management regimens must
be individualized to the client and
consider medical, psychological
and physical condition, age, level
of fear or anxiety, surgical
procedure, client goals and
preference, and previous response
to analgesics (Ackley & Ladwig,

Evaluation of Interventions on
Day care is Provided
The patient was assessed for pain
and asked if she needed her PRN
pain medication frequently
throughout the shift. Pain
medication was typically
administered when pain exceeded a
6 or 7 out of 10, per patients
request. Post-administration of pain
medication, patient reported pain at
a 2-3 out of 10.
The patient was taught how and
when to use sublingual
nitroglycerin. The patient
understood the teach, as she
modeled when and how the
nitroglycerin should be
administered.
I discussed with the patient her
experience with pain and how she
currently manages pain. The patient
has thorough experience with pain,
as she has suffered with thoracic
outlet syndrome the majority of her
adult life. Unfortunately, the patient
is unable to get pain medication
prescribed by her PCP and cannot
afford to see a pain management
physician. Therefore, the patient
self medicates with marijuana on a
regular basis. Her pain is managed
at a tolerable level at home. While
in the hospital, the patients pain
has been managed at a tolerable

2014, pp. 577)

level through opioid analgesics.

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:
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, MO: Elsevier.
AACC: American Association for Clinical Chemistry. (2015). About Lab Tests Online. Retrieved
from https://labtestsonline.org/
Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO:
Elsevier.
Osborn, K.S., Wraa, C.W., Watson, A.B., & Holleran, R. (2014). Medical-surgical nursing:
Preparation for practice (2nd ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Treas, L., & Wilkinson, J. (2014). Basic nursing: Concepts, skills, & reasoning. Philadelphia,
PA: F.A. Davis Company.
Unbound Medicine, Inc. (2015). Nursing Central (Version 1.26). [Mobile application software].
Retrieved from http://itunes.apple.com
USDA: United States Department of Agriculture. (2015). Choose MyPlate. Retrieved from
http://www.choosemyplate.gov/about