UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jessica Rowe

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.

Agency: LRMC VCARE

1 PATIENT INFORMATION
Patient Initials:
Gender:

CR
M

Age:

Assignment Date: 10/20/2015

59

Marital Status: Married

Admission Date: 10/19/2015

Primary Medical Diagnosis: Pulmonary fibrosis

Primary Language: English

Level of Education: High School

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Drives a tractor

CHF, Hypertension, Interstitial lung disease,

pulmonary edema, pulmonary hypertension,

Number/ages children/siblings: 3

Served/Veteran: No
If yes: Ever deployed? Yes or No

Code Status: Full Code

Living Arrangements: At home with wife, and children. Oxygen

dependent at home.

Advanced Directives: No
If no, do they want to fill them out? Yes
Surgery Date: 10/23/2015
Procedure: cardiac Catheterization

Culture/ Ethnicity /Nationality: Mexican

Religion: Roman Catholic

Type of Insurance:

Humana HMO/POS

1 CHIEF COMPLAINT: Shortness of Breath/ woke up in the middle of the night felt like he was
choking, swelling in lower extremities X10 days

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
59 y/o male presents to ED by ambulance with shortness of breath and swelling in lower extremities x10 days. Is
oxygen dependent at home 4-6 L via Nasal Cannula. Oxygen saturation 71%, placed on face mask and admitted to unit.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date

Operation or Illness

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)

Alcoholism

2
FAMILY
MEDICAL
HISTORY

Lung biopsy
Mediastinoscopy
SCT Kidney Biopsy
SCL Right Side Heart Catheterization

Age (in years)

2014
3/7/2014
10/21/2015
10/23/2015

Father
Mother
Brother
Sister
relationship
relationship
relationship

Comments: pt does not know medical history of father, and does not know where the father is.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Unknown
Routine adult vaccinations for military or federal service
N/A
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or

YES

University of South Florida College of Nursing Revision September 2014

NO

occupational purposes? Please List

If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Lovenox

Type of Reaction (describe explicitly)

Pt states that he had the shot one time and he ended up in the ICU

Medications

N/A
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment): Idiopathic Pulmonary fibrosis is the most common idiopathic interstitial lung disorder. More
common in men than in women and most cases occur after the age of 60. IPF is characterized by chronic
inflammation but recent studies show that ir results from aberrant healing responses to epithelial cell injury.
Fibroporliferation of the interstitial lung tissue around the alveoli causes decreased oxygen diffusion across the
alveolocapillary membrane which leads to hypoxemia, As the disease progresses, decreased lung compliance
leads to increased work of breathing, decreased tidal volume and resultant hypoventilation with hypercapnia.
The primary symptom of IPF is increasing dyspnea on exertion. Physical examination reveals diffuse inspiratory
crackles. The diagnoses is confirmed by pulmonary function testing the patient will have decreased FVC, high resolution
computed tomography, and lung biopsy. Treatments includes corticosteroids and cytotoxic drugs, although success rates
are low and toxicities are high. Newer therapies include anitfibrotic drugs (such as N-acetylcyteine and pirfenidone,
interferon, and anticoagulation therapy. Selected individuals may benefit from lung transplantation.

5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name: Albuterol
Route

Concentration

Nebulizer solution

Pharmaceutical class
Indication

adrenergic

2.5 mg

Dosage Amount 0.5 mL

Frequency Q 6 hours
Home and Hospital

COPD

University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: Nervousness, headaches, insomnia, paradoxical bronchospasms, chest pain, palpitations, hyperglycemia, nausea, vomiting,
Nursing considerations/ Patient Teaching Teach patient proper use of the Nebulizer, explain to the patient why they are being given this medication, express to
the patient that if they smoke they should quit, find out what type of work the patient does and if they should consider changing occupations,
Name Flonase
Route

Concentration 0.5 mg

Nasal Spray

Pharmaceutical class
Indication

Dosage Amount
Frequency

Corticosteroid

1 spray

Daily

Hospital

Seasonal or Perennial nonallergic Rhinitis

Adverse/ Side effect: Headache, epistaxis, nasal irritation, nasopharyngeal fungal infection, nausea, vomiting, adrenal suppression, decreased growth, cough,
Anaphylaxis, Angiodema
Nursing considerations/ Patient Teaching Monitor degree of nasal stuffiness, amount and color of nasal discharge, monitor frequency of sneezing, monitor
growth rate in children, monitor for signs and symptoms of hypersensitivity reactions (rash, pruritis, swelling of face and neck, dyspnea) Advise the patient to
take the medication exactly as directed, instruct the patient on the correct technique for using the nasal spray, Instruct the patient to stop using the medication if
signs and symptoms of anaphylaxis occur, the patient should notify the provider of all OTC medications for incase of drug to drug interactions, this medication
is pregnancy class C so if the patient is female she should notify the provider if she becomes pregnant or is breast feeding.
Name

Lasix (furosemide)

Concentration 40 mg

Route IV push
Pharmaceutical class
Indication

Dosage Amount

4 mL

Frequency BID
loop diuretic

Hospital

edema due to heart failure or renal disease

Adverse/ Side effects blurred vision, dizziness, headache, hypotension, anorexia, constipation, dry mouth, increased liver enzymes, nausea, vomiting, increased
BUN excessive urination, Steven-Johnsons Syndrome, Erythema Multiforme, Toxic Epidermal Necrolysis, photosensitivity, dehydration, hypokalemia,
hyponatremia, muscle cramps
Nursing considerations/ Patient Teaching: Instruct the patient to take the medication as directed, do not double doses, caution patient to change positions
slowly to minimize risk for orthostatic hypotension, let the patient know that the use alcohol may induce orthostatic hypotension, Tell the patient that they
should contact their health care provider if they gain more then 3 pounds in 1 day. The patient should use sunscreen and protective clothing when outdoors, the
patient should contact their health care provider immediately if they experience a rash, muscle cramps, nausea, dizziness, numbness or tingling in the
extremitites,
Name Lasix

Concentration 20 mg

Route Oral

Frequency BID

Pharmaceutical class loop diuretic

Indication

Dosage Amount 1 tab

Home

edema due to heart failure and renal disease

Adverse/ Side effects blurred vision, dizziness, headache, hypotension, anorexia, constipation, dry mouth, increased liver enzymes, nausea, vomiting, increased
BUN excessive urination, Steven-Johnsons Syndrome, Erythema Multiforme, Toxic Epidermal Necrolysis, photosensitivity, dehydration, hypokalemia,
hyponatremia, muscle cramps
Nursing considerations/ Patient Teaching Instruct the patient to take the medication as directed, do not double doses, caution patient to change positions
slowly to minimize risk for orthostatic hypotension, let the patient know that the use alcohol may induce orthostatic hypotension, Tell the patient that they
should contact their health care provider if they gain more then 3 pounds in 1 day. The patient should use sunscreen and protective clothing when outdoors, the
patient should contact their health care provider immediately if they experience a rash, muscle cramps, nausea, dizziness, numbness or tingling in the
extremitites,
Name Singulair
Route

Concentration

10 mg

Oral

Dosage Amount
Frequency

Pharmaceutical class leukotriene antagonists

1 tab

qhs

Home and Hospital

Indication Management of seasonal allergic rhinitis

Adverse/ Side effects: Suicidal Thoughts, agitation, anxiety, depression disorientation, dream abnormalities, insomnia, headaches, nosebleeds, otitis in
children, sinusitis in children, cough, abdominal pain, diarrhea, dyspepsia, Stevens-Johnson syndrome, Toxic Epidermal Necrolysis
Nursing considerations/ Patient Teaching instruct the patient to take daily in the evening or 2 hours before exercise, do not double doses, do not discontinue the
medication without consulting health care provider, the patient should be alert for occurrences of anxiety, insomnia, irritability, hostility, mania, depression,
suicidal ideation and if theses symptoms occur they should notify a heath care professional immediately.
Name

Diltazem

Route

Oral

Dosage Amount
Frequency

Pharmaceutical class
Indication

Concentration 120 mg

Calcuim Channel blocker

Home and

1 cap

daily

Hospital

hypertension, angina pectoris, SVT,

Adverse/ Side effects abnormal dreams, anxiety, confusion, blurred vision, psychiatric disturbances, disturbed equilibrium, tinnitus, cough, Arrhythmias,

University of South Florida College of Nursing Revision September 2014

Heart Failure, Peripheral edema, chest pain, palpitations, syncope, dysuria, sexual dysfunction, Stenvens-Johnsons Syndrome, erythemia, sweating,
photosensitivity, weight gain, gingival hyperplasia, muscle cramps
Nursing considerations/ Patient Teaching Pt should take the medication at the same time every day as prescribed, do not double doses, Avoid large amounts of
grapefruit juice, teach patient how to monitor his/her pulse, instruct patitent to change positions slowly to minimize orthostatic hypotension, may cause
drowsiness/dizziness and he/she should avoid driving. Pt should notify the healthcare provider if they experience rash, irregular heart beats, dyspnea, swelling
of hands and feet, pronounced dizziness, constipation, nausea, hypotension, or headaches.
Name

Methylprednisolone

Route

Injection

Pharmaceutical class
Indication

Concentration 40 mg

Dosage Amount 1 mL
Frequency

corticosteroid

every 6 hours

Hospital

replacement therapy in adrenal insufficiency

Adverse/ Side effects

depression, euphoria, headache, personality changes, cataracts, increased intraocular pressure, hypertension, peptic ulceration,
anorexia, nausea, vomiting, decreased wound healing ecchymosis, petechiae, hyperglycemia, adrenal suppression, Thromboembolism, weight gain or loss,
muscle pain,
Nursing considerations/ Patient Teaching Instruct patient to take the medication as directed, do not double doses, do not stop medication suddenly due to risk
of adrenal insufficiency, anorexia, nausea, weakness, fatigue, hypoglycemia. May cause immunosuppression and can mask sympotoms of infection so they
should avoid people with known contagious illnesses. Pt should notify provider if they experience severe abdominal pain or tarry stools, unusual swelling,
weight gain, tiredness, bone pain, bruising, non healing sores, visual disturbances, or behavior changes. Pt should notify their provider of any medications that
they are taking including dietary supplements or herbal supplements.
Name

Levofloxacin (levoquin)

Route

Concentration 750 mg

IV

Pharmaceutical class
Indication

Dosage Amount
Frequency

fluroquinolones

total volume

Daily

Hospital

Respiratory tract infections, acute exacerbations of chronic bronchitis, community-acquired pneumonia

Adverse/ Side effects Increased Intracranial pressure, Seizures, agitation, anxiety, confusion, drowsiness, insomnia, headache, paranoia, nightmares,
Hepatotoxicity, Pseudomembranous Colitis, abdominal pain, vomiting, vaginitis, Stevens-Johnsons Syndrome, hyperglycemia, peripheral neuropathy,
tendonitis, tendon rupture, Anaphylaxis
Nursing considerations/ Patient Teaching Take medication daily at evenly spaced times, the patient should complete the medication as prescribed even if
feeling better, do not double dose, do not share medications, notify health care providers if they are taking theophylline, antacids should not be taken 4 hours
before or 2 hours after taking this medication, may cause dizziness or drowsiness, notify health care professionals if they have a history of QT prolongnation,
recent hypokalemia, significant bradycardia, or recent myocardial ischemia. The patient should stop taking this medication immediately if they notice
peripheral neuropathy, the patient should report any signs of superinfection
Name

Insulin Lispro

Concentration

unit

Route InJ

Frequency

Pharmaceutical class Pancreatics

Indication

Dosage Amount

sliding scale

PRN

Hospital

control of hyperglycemia

Adverse/ Side effects hypoglycemia, erythema, pruritis, allergeic reactions including anaphylaxis
Nursing considerations/ Patient Teaching
instruct paitent on proper technique for administration and include equipment, the patient should rotate injection
sites, insulin pens should not be shared with other people, explain that the medication is for control of hyperglycemia, teach the patient how to properly test
blood glucose levels, teach the patient importance of following nutrition guidelines, Pt should notify health care providers if they experience nausea, vomiting,
fever, if unable to eat a regular diet, if glucose levels are not controlled, Instruct the patient on how to identify the signs and symptoms of hypo/hyperglycemia
and what to do if they occur.

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Cardiac diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast:
Coffee, toast, banana
According to My plate, the patient needs to add dairy to his
diet, he needs to cut back on his refined grains and his
protein. And he should incorporate more fruits into his
diet.
Lunch:

chicken, rice, 2 tortillas

Dinner:

tacos with steak, rice, black beans,

Snacks:

peanuts, crackers,

Liquids (include alcohol): 1.5 L 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 a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Wife, Rosa, and children
How do you generally cope with stress? or What do you do when you are upset?

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

+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

University of South Florida College of Nursing Revision September 2014

___

If yes, have you sought help for this? ______________________

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

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

Generativity vs Stagnation (40-65 years): 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. Simply having children does not guarantee generativity.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient has achieved generativity, I determined this because my patient has meaningful relationships with his wife and children
and he is still contributing to society through his occupation.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The impact that being in the hospital could have on the patient is that if he is missing too much work or ends up unable to work
and provide for his family it could make him feel like a failure.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? That I used to smoke cigarettes

What does your illness mean to you? It makes it a little more difficult for me to do my job and provide for my family. I
am hoping that the new owner of the company I work for will allow me to continue driving the tractor and to take breaks
if needed.

+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

University of South Florida College of Nursing Revision September 2014

Have you ever been sexually active? Yes

Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No
Are you currently sexually active? No___________________________ If yes, are you in a monogamous relationship?
____________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ________________________________
How long have you been with your current partner?

35 years _______________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? Yes

_____________________

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 September 2014

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

What importance does religion or spirituality have in your life?
Somewhat important __________________________________________________________________________
______________________________________________________________________________________________________
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)
Former smoker
pack daily

Yes
For how many years? 15 years
(age 15

thru 30

If applicable, when did the

patient quit? 1984 or 1985

Pack Years: 8 years

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

Has the patient ever tried to quit?

If yes, what did they use to try to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer
How much? 3
Volume: 12 oz
Frequency: daily
If applicable, when did the patient quit?
3 years ago

Yes
For how many years?
(age

thru 56

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other?
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
equipment

Operates heavy

5. For Veterans: Have you had any kind of service related exposure? N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
How do you view your overall health? fair

Integumentary: Patient denies any changes in appearance of skin, patient denies having any problems with
nails, no clubbing is evident, Pt denies having any dandruff and none noted, pt denies having any psoriasis,
hives or rashes, Pt is free from any skin infections or breakdown, Pt bathes daily. Pt has good skin turgor, skin is
warm dry and intact
HEENT: Pt denies any difficulties seeing, pt denies any difficulties hearing and responds well to my questions,
Pt denies having cataracts or glaucoma, Pt does not have any ear infections, Pt denies having any sinus pain or
infections. Pt denies nosebleeds or post-nasal drip. Pt denies having dental problems and states that he brushes
his teeth regularly, gets his vision checked and has routine dental visists once a year. Ears are free from any skin
breakdown.
Pulmonary: Pt states he has difficulty breathing, denies having any pain and states that when he has difficulty
breathing its like a tightness in his chest and its like he is choking. Pt states that he uses his inhaler when this
occurs. Pt denies having a cough, Asthma, Bronchitis, Emphysema, pneumonia, Tuberculosis, or any
environmental allergies. Pt has been diagnosed with pulmonary fibrosis
Cardiovascular: Pt states he has hypertension and denies having any chest pain, Pt denies having
hyperlipidemia, Pt denies having Myocardial Infarction, Pt denies having Coronary Artery Disease, Pt states that
he has been told that he has Congestive Heart Failure, Pt denies having any murmurs, Pt denies having any
thrombus, Pt denies having rheumatic Fever, Pt denies having myocarditis, pt has right bundle branch block
verified by EKG on 10/19/2015.
GI: Pt denies any nausea, vomiting or diarrhea, Irritable Bowel, or cholecystitis. Pt denies any constipation, Pt
denies having GERD, Pt denies Indigestion, Pt denies having any hemorrhoids, Pt does not have jaundice,
pancreatitis, Pt denies colitis, diverticulitis, appendicitis, Gastritis, hepatitis, or any blood in his stool. Pt denies
having any abnormal abscesses.
GU: Pt voids on his own, denies having any pain during urination, denies any history of kidney stones, Pt
denies having any blood in his urine, pt denies having any recent bladder or kidney infections. Pt was found to
have vasculitis of the lower pole in the Left Kidney by kidney biopsy done on 10/21/2015
Women/Men Only: Pt denies any infection of the male genitalia and prostate, Pt states that he gets regular
prostate exams but the date of the last exam is unknown. Pt denies having any Urinary retention.
Musculoskeletal: Pt denies any recent injuries or fractures, Pt denies having any muscle weakness, Pt denies
having any pain, Pt denies having gout, Pt denies having arthritis, pt denies osteoporosis or osteomyelitis. Pt
denies using any walkers or devices at home.

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10

Immunologic: Pt denies any chills or shaking, or tremors. Pt denies any night sweats or fever, Pt denies having
HIV or AIDS, Pt denies having lupus, Pt denies having Rheumatoid Arthritis. Pt denies sarcoidosis. Pt denies
having any life threatening allergic reactions other than lovenox, Pt stated that he received the shot one time five
months ago and ended up in the ICU and states that he still has a bruise from that shot
Hematologic/Oncologic: Pt denies having anemia, states that he does not bleed or bruise easily, Pt denies
having cancer and denies family history of cancer, Pt did receive a blood transfusion one time after a procedure
but cannot remember the date. Blood type is unknown
Metabolic/Endocrine: PT denies having diabetes, Pt denies any hyper/hypothryroidism, Pt denies having any
intolerances to heat or cold.
Mental Illness: Pt denies having any depression, schizophrenia, anxiety, or schizophrenia
Childhood Diseases: Pt denies to the best of his knowledge having Measles, Mumps, or chicken pox, pt denies
having polio, pt denies having scarlet fever.
Central Nervous System: Pt denies having any history of strokes or CVA, Pt denies having any dizziness, pt
denies sever headaches or migraines, Pt denies any seizures, ticks or tremors, pt denies having encephalitis or
meningitis.

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

10 PHYSICAL EXAMINATION:
General survey _____________________________________________________________________________________
Height 173 CM / 5 ft 8 in Weight 81.1 kg / 178.42 lbs BMI 27.1 Pain (include rating and location) no pain
Pulse 95 ____ Blood Pressure (include location) 117/71 Left Arm ___Temperature (route taken)
35.7 C Oral
Respirations 18
SpO2 99%
Room Air or O2 Face Mask 15L ______________
Overall Appearance: pt is sitting up in bed, room is free of clutter, _____________________
Overall Behavior Patient is calm and cooperative, responds to commands ____________________________
Speech: speech is good and not slurred _____________________________________________________
Mood and Affect Pt is in a good mood and is laughing and joking _____________________________________
Integumentary skin is warm, dry and intact free from any lesions or rashes, ______
IV Access pt has a 18 Gauge Peripheral IV in his left antecubital. ____________________________
HEENT Facial features are symmetrical, pt denies any pain in his sinuses, pt denies pain in his jaw and is free from
clicks, No sign of tracheal deviation, Thyroid is not enlarged, Pt does not have any palpable lymph nodes, Sclera is
white and conjunctiva is pink and free of discharge, Eyebrows, eyelids, and eyelashes are symmetrical, lacrimal
glands are symmetric without any edema or tenderness and free from buildup. Pupils are Equal Round Reactive to
light and are 2 mm in size. Peripheral vision is intact, all extra ocular movements are intact and free from

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11

nystagmus, ears are symmetrical and free from any lesions or discharge, Pt does not have any hearing difficulties
and is responding well to my questions, Nose is without lesions or discharge and the mucus membranes are pink and
moist, Lips are intact and free from lesions, oral cavity is healthy and free from lesions, oral mucosa is pink and
moist.
Pulmonary/Thorax: Respirations are regular and unlabored, crackles heard in lower lobes, upper lobes clear, chest
is symmetrical and not barreled, Transverse ratio is 2:1, Pt does not produce any sputum, pt is on oxygen via
facemask and is oxygen dependent at home via nasal cannula, Pt knows how to use an incentive spirometer,
Cardiovascular: Normal rate and rhythm, S1 and S2 present, no bruits, Pulses in upper extremities are strong and
equal, pulses in lower extremities are diminished +1 due to edema 3+, No murmurs, clicks, or adventitious sounds
heard, No JVD, PMI palpated no thrill, heaves, or lifts noted.
GI: Bowel sounds heard in all four quadrants normoactive, no aortic Bruits heard, Percussion over liver and spleen
is dull, tympanic over stomach and intestines, abdomen is soft and non-tender, free from masses or abnormalities,
Patient states last bowel movement was on 10/20/2015 and states that it was formed and medium brown, pt denies
any pain or tenderness. Pt denies any nausea or vomiting
GU: Pt voids without assistance, unable to assess for color and clarity, the patient denies having any pain or burning
when urinating, Pt denies any strong odors and states that his urine is normal. Pt denies having any rebound
tenderness_________
Musculoskeletal: Pt has full ROM in all extremities without crepitus, Pts gait is steady and strength is 5 out 5. Pt is
free from any spinal deformities, Pt denies having any pain in his joints or muscles, _____________
Neurological: Patient is awake and alert oriented to person place and date, Cranial Nerves 2-12 are intact, sensation
is intact to touch pain and vibration, Pt is negative for Romberg, Reflexes not assessed.

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):
EKG Sinus Rhythm with a Right Bundle Branch Block
Portable Chest X-ray slight enlargement of the cardiomediastinal and pulmonary vascular congestion
Kidney Biopsy Lower pole Left kindney vasculitis
SCL Right side Heart catheterization: Severe pulmonary Hypertension with no significant reversibility after
Adenosine challenge, Non-flow limiting CAD with mild Calcific plaque, PA pressures mean 60-65
mmHg with no significant change after Adenosine challenge
Echo from septer 30 shows preserved LV/RV systolic function 55-60

Lab
WBC 7.2
Hgb 14.6
HCT 45.2
Platelets 16.5

Dates

Na 137
K 3.3
Cl 102
Co2 22
BUN 15
Cr 1.1
Glu 142
BNP 582
Troponin 0.02

10/20/2015

10/20/2015

Trend
No trend available this is
the 1st day of admission

Analysis

10/20/2015
10/20/2015
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12

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Pt is on a cardiac diet and fluid restriction of 1.5 L of fluid per day, pt receives breathing treatments from
respiratory therapy to help open up his lungs and get some of the fluid off. He is receieving Lasix to help reduce
the edema in his lower extremities, the patient has been instructed to avoid salt. Since he is receiving Lasix, he
will be getting lab work to monitor his sodium and potassium. He is also getting steroids to help get the fluid off
his lungs and even though he is not diabetic we will be monitoring his blood sugars because the steroids can
cause an increase in his blood sugar.

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

1.Ineffective breathing pattern related to pulmonary function as evidenced by patient stating that he couldnt catch his
breath and felt like he was choking.
2. Fluid volume excess R/T compromised regulatory mechanism as evidenced by lower extremity edema and weight gain
3. Impaired gas exchange R/T ventilation perfusion imbalance as evidenced by oxygen saturation of 71% upon admission
4.
5.

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13

 15 CARE PLAN

Participate in actions to maximize

oxygenation, improve ventilation

Nursing Diagnosis: Nursing Diagnosis goes here

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
Assess respiratory rate and depth,
Symptoms of respiratory symptoms
monitor pulse oximetry
are dependent and indicative of the
degree of lung involvement and
can give an impression of the
overall general health staus.

Maintain Clear lung fields and

remain free of respiratory distress

Administer oxygen therapy by

appropriate means

Giving oxygen therapy helps to

maintain appropriate oxygen
saturation levels allowing the
tissues to be properly oxygenated.

Elevate head of bed, put patient in

chair, encourage deep breathing
and coughing,

Promotes maximum chest

expansion, mobilizes secretions
and promotes better ventilation

Give lasix

Rid the body of the excess fluid

that builds up enabling the patient
to breathe better, also to allow the
heart to beat effectively allowing
the tissues to be properly prefused

Patient Goals/Outcomes

Remove the excess fluid and

decrease lower extremity edema

Evaluation of Goal on Day Care

is Provided
On admission pt had o2 saturation
of 71%, placed on facemask 15L,
pt was weaned off the face mask
and was maintaining an oxygen
saturation of 93-94% on 6 L Nasal
canuala

Lasix administered, patient voided

A long term goal would be to

participate in prevention of further
complications

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Include a minimum of one

Long term goal per care plan
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
x Dietary Consult- the patient should see a dietician so that they can learn what food to eat and what foods to stay away from and the importance of
why they should not eat these foods for instance the patient should avoid salt so they he does not retain as much water.
PT/ OT
Pastoral Care
Durable Medical Needs
x F/U appointments the patient should have a follow up with the pulmonologist so that his pulmonary fibrosis and CHF can be monitored as well as
his new diagnosis of pulmonary hypertension. It will also be important for the patient to have follow up appointments to make sure that any
medications that he is on are the appropriate prescriptions and doses.
x Med Instruction/Prescription there should be a thourough explanation of any new medications that the patient is placed on as far as what it is is,
what it does and what side effects that it has.
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

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References

Sue E . Huether, Kathryn L. McCance Understanding Pathophysiology, fifth edition pg 686

Leslie s. Treas, Judith M. Wilkinson Basic Nursing Pg 164

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