UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Eduardo Alegria

FUNDAMENTAL PATIENT ASSESSMENT TOOL

.

Assignment Date: 10 Nov 15

Agency: TGH

1 PATIENT INFORMATION
Patient Initials: E.H.

Age: 86

Admission Date: 02 Nov 15

Gender: Female

Marital Status: Widowed

Primary Medical Diagnosis: Atrial fibrillation

Primary Language: English

Level of Education: BSN-RN

Other Medical Diagnoses: Tachycardia, other

fatigue, diaphoresis, palpitations, CHF
exacerbatuons.

Occupation (if retired, what from?): RN/ Retired

Number/ages children/siblings: 3 Females/62, 60, 57/7 Brothers,
6 Sisters, 1 Sister still alive
Served/Veteran: No
If yes: Ever deployed? N/A

Code Status: Not on file

Living Arrangements: First Floor Assisting Living in Tampa. There

are not stairs in the apt. Daughters visit her frequently.

Advanced Directives: Yes, Living Will.

Surgery Date: N/A

Procedure: N/A

Culture/ Ethnicity /Nationality: Caucasian/American

Religion: Catholic

Type of Insurance: Medicare A& B, Humana

Medicare Supplement

1 CHIEF COMPLAINT: I had no pain, zero symptoms other than irregular heart beat.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay) On the afternoon of 01 Nov 2015 the patient was in her assisted living department when she reported irregular
heartbeat. The patient felt arrhythmia so she called 911. An ambulance was sent and patient transferred to ER at TGH.
After arriving to the ER, a physician ordered blood samples, ECG, and chest X-Rays. Patient was admitted to TGH
Cardiac Unit for monitoring on the same day due to atrial fibrillation, diaphoresis, palpitations, and other CHF
exacerbations. Patient reports she experienced no pain of the chest or otherwise. On the third day of her hospital stay,
patient is successfully sitting up to eat and ambulating to the restroom. Patient reportedly feels up to walking the floor,
despite presenting with high blood pressure. Patient is receiving vitamins, anti-coagulant medications, and ace-inhibitor
medications.

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

Operation or Illness
Varicose Vein Stripping
L total knee replacement
Hysterectomy

University of South Florida College of Nursing Revision September 2014

5
0
9
8

Father
Mother

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Hypertension
Problems
Kidney

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

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Anemia
Arthritis

Environmental
Allergies

Cause
of
Death
(if
applicab
le)

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Suicide
Old age

Brother
Sister
relationship
relationship
relationship

Comments: PT reported seven brothers and six sisters. Although Parkinson disease found in four brothers PT
doesnt remember the absolute cause for her brothers and sisters death. PT also reported that one of her sister
still alive. There was not a following question as where she resides.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (U)
Adult Tetanus (U) Is within 10 years?
Influenza (flu) (U) Is within 1 years?
Pneumococcal (pneumonia) (U) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? No travel outside the U.S.
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

NO

Type of Reaction (describe explicitly)

NONE
Medications

NONE
Other (food, tape,
latex, dye, etc.)

University of South Florida College of Nursing Revision September 2014

 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) Atrial fibrillation is related to atrial fibrosis and loss of muscle mass in the atrium which could be due
to genetics, the aging process, inflammatory, and dilation processes in the chamber and often is associated with
hypertension and congestive heart failure. The dilation of the atria activates the renin-aldosterone-angiotensin
system (RAAS), which eventually leads to atrial remodeling and/or fibrosis. ACE inhibitors are often an
effective way to lower atrial pressure and chamber wall stress. Fibrosis not only acts on the muscle mass to the
atria, but can also act on the sinoatrial and atrioventricular nodes, with subsequent sick sinus syndrome. In
atrial fibrillation, the impulses created by the sinus node can be overpowered by erratic electrical discharge
produced by bigger areas of atrial tissue. Labs, ECG, and chest X-Rays are often utilized in the diagnosis for
atrial fibrillation (Pathophysiology 2008). The treatment for atrial fibrillation is resetting the hearts rhythm and
preventing of blood clots (Atrial Fibrillation 2014). Maintaining normal blood pressure through diet, exercise,
or medications when warranted, assist in the prevention of blood clots and irregular heartbeat. Recommended
guidelines often include the avoidance of alcohol, nicotine, and stimulant medications. In the event these
conditions cannot be controlled, heart medications and/or a pacemaker may be necessary in the treatment of
patients with this condition (Case-Lo, C. (2013).
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: apixaban (Eliquis)

Concentration:

Route: PO

Dosage Amount: 5mg

Frequency: BDS

Pharmaceutical class: Anticoagulant Medication

Home:

Hospital: X

or

Both:

Indication: apixaban is used on patients with atrial fibrillation; prevents the risk of strokes by keeping the platelets form coagulating inside the veins.
Adverse/ Side effects: Blood and lymphatic system disorders, G.I. hemorrhage, ecchymosis/Increased risk of thrombotic events after premature discontinuation, bleeding
Nursing considerations/ Patient Teaching: Increased risk of bleeding while taking them with other anticoagulants/Instruct patient to take apixaban as directed, inform
patient that they might bruise and bleed more easily. Notify the physician if signs of bleeding occur or if any injury occurs, especially head injury
Name: aspirin

Concentration

Dosage Amount: 81mg

Route: PO

Frequency: q daily

Pharmaceutical class: Anticoagulant Medication

Home:

Hospital:

or

Both: X

Indication: Decreases platelets aggregation is also use for its analgesic effects and to reduce inflammation and fever.
Adverse/ Side effects: GI bleeding, anaphylaxis, laryngeal edema/dyspepsia, nausea, abdominal pain, vomiting, rash, uticaria
Nursing considerations/ Patient Teaching: Monitor for the onset of tinnitus, hyperventilation, agitation, mental confusion/Instruct patient to avoid use od alcohol to
minimize gastric irritation, avoid taking it with acetaminophen od NSAIDs to prevent analgesic nephropathy
Name: calcium vitamin D (Oscal)

Concentration:

Route: PO

Dosage Amount: 250-125 mg unit per tablet

Frequency: q daily

Pharmaceutical class: Vitamin D

Home:

Hospital: X

or

Both:

Indication:
Adverse/ Side effects: Stomach pain, vomiting, loss of appetite, increased thirst or urination/nausea, weakness, constipation
Nursing considerations/ Patient Teaching: Monitor irregular heartbeats, confusion/Instruct the patient to contact the physician if symptoms such as confusion, increase
urination, thirst, weakness, and feeling tired or restless occurs
Name: cholecalciferol (vitamin D3)

Concentration

Dosage Amount: 1000 units

Route: PO

Frequency: q daily

Pharmaceutical class: Vitamin, fat soluble vitamin

Home:

Hospital: X

or

Both:

Indication: Vitamin D deficiency

Adverse/ Side effects: Hypervitominosis D and Lipids abnormal/Constipation, nausea, vomiting
Nursing considerations/ Patient Teaching: No additional vitamin D supplements/ Instruct the patient to contact the physician if symptoms such as confusion, increase
urination, thirst, weakness, and feeling tired or restless occurs

University of South Florida College of Nursing Revision September 2014

Name: docusate sodium (Colace)

Concentration

Dosage Amount: 100mg

Route: PO

Frequency: BDS

Pharmaceutical class: Stool softener

Home

Hospital

or

Both

Indication: To treat or prevent constipation

Adverse/ Side effects: Rectal bleeding or irritation, severe diarrhea or stomach cramps/mild diarrhea, mild nausea
Nursing considerations/ Patient Teaching: Avoid using laxatives or other stool softeners/Tell patient not to take drug if experiencing acute abdominal pain, this drug
may cause a bitter taste in the mouth, instruct the patient if any rectal bleeding occurs
Name: famotidine

Concentration

Dosage Amount: 20mg (injection or tablets)

Route: Injection or PO

Frequency: BDS

Pharmaceutical class: Duodenal ulcer disease

Home:

Hospital: X

or

Both:

Indication: Indigestion
Adverse/ Side effects: Atrioventricular block, bradyarrhytmia/Constipation, dizziness, headaches
Nursing considerations/ Patient Teaching: Monitor patients with moderate to severe renal insufficiency/Tell the patient that this drug may cause constipation, diarrhea
dizziness, instruct patient to take at bed time
Name: losartan (Cozaar)

Concentration

Dosage Amount: 50mg

Route: PO

Frequency: q daily

Pharmaceutical class: Angiotensin Receptor Blockers (ARBs)

Home:

Hospital:

or

Both: X

Indication: Treatment of hypertension

Adverse/ Side effects: Hypotension, allergic reaction/Diarrhea, muscle cramps, dizziness, nasal congestion
Nursing considerations/ Patient Teaching: Increased risk for electrolyte imbalance in patients with renal deficiencies, monitor patients with hepatic impairment/This
medication may be taken with or without food, do not consume alcohol, check with your doctor if you have severe nausea, vomiting, or diarrhea
Name: metropolol succinate (Tropol)

Concentration

Dosage Amount: 100mg

Route: PO

Frequency: BDS

Pharmaceutical class: Beta-Blocker

Home:

Hospital:

or

Both: X

Indication: Hypotension, congestive heart failures, acute myocardial infarction, angina

Adverse/ Side effects: Bronchospasm/Cold extremities, dizziness, fatigue, constipation, diarrhea, nausea
Nursing considerations/ Patient Teaching: Monitor patients with hepatic impairment, and renal failure/Caution patient to drive or use of heavy machinery until drug
effects are realized, tell patient planning a major surgery to alert physician that this drug is being used. Diabetic patients should monitor their glucose levels carefully
Name: propafenone (Rythnol SR)

Concentration:

Route: PO

Dosage Amount: 12 Hr Capsule 325mg

Frequency: BDS

Pharmaceutical class: Antiarrhythmic drug

Home:

Hospital:

or

Both: X

Indication: Atrial fibrillation and flutter

Adverse/ Side effects: Cardiac arrest, angina, congestive heart failure/Constipation, nausea, taste sense altered, dizziness, anxiety, edema, chest pains
Nursing considerations/ Patient Teaching: Renal impairment, hepatic impairment; potential increased risk of toxicity/Advise patient to report symptoms of angina, new
or worsened arrhythmias, CHF, instruct patient to avoid activities requiring mental alertness until drugs effects are realized
Name: simvastatin (Zocor)

Concentration:

Route: PO

Dosage Amount: 80mg

Frequency: once nightly

Pharmaceutical class: Statin class, cholesterol lowering drugs

Home:

Hospital:

or

Both: X

Indication: High cholesterol, prophylaxis in patients with high coronary event risks
Adverse/ Side effects: Jaundice, liver failure, increased liver enzymes, compartment syndrome of lower leg/Abdominal pain, constipation, nausea, headaches
Nursing considerations/ Patient Teaching: check for myopathy and rhabdmyolosis with and with out acute renal failure/Instruct patient to report signs and symptoms of
myopathy and rhabdmyolosis, as well as liver injury. Instruct patient to avoid grapefruit juice while taking drug

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?
Analysis of home diet: As the graph shows, this patient
is
Diet patient follows at home?
lacking dairy in her diet. She should increase diary
maybe
24 HR average home diet:
mixing cottage cheese, yogurts, or fruit shakes adding
some
Breakfast: scrambled eggs, fruit cup, occasionally
milk as her daily snacks. She should also increase her
bacon
and oatmeal
whole grains intake by eating all-bran cereals, whole
wheat
Lunch: salad, grilled salmon
pastas at lunch and maybe even wheat toasts with her
breakfast. She is doing an amazing job by eating
509mg of
Dinner: fish, chicken, occasionally red meat
her daily allowed sodium intake. She also could eat a
little
bit more vegetables so as to increase her level of
minerals
Snacks:
that are in vegetables.
Liquids (include alcohol): water, tea, no alcoholic
bevarages are consumed by this patient

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
-Patients states her daughter helps her as her daughter works at TGH as nurse in the cardiac unit
How do you generally cope with stress? or What do you do when you are upset?
-Patient states that she is not usually upset and when she is, she thinks about the issue and solves it herself

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
-Patient denies feeling depressed, although she felt a little depressed a year and a half ago due to the inability to
talk to her
better half as she was used to do it for forty-three years.
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently

University of South Florida College of Nursing Revision September 2014

are unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that
you are safe.
Have you ever felt unsafe in a close relationship? NO
Have you ever been talked down to? NO Have you ever been hit punched or slapped? NO
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? NO
If yes, have you sought help for this?
Are you currently in a safe relationship? N/A

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Industry vs.
Integrity vs.

Inferiority
Despair

Identity vs.

Trust vs. Mistrust

Role Confusion/Diffusion
Intimacy vs.

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Isolation
Generativist vs. Self absorption/Stagnation
Ego

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons
developmental stage for your
Patients age group: -My patients age was 86. She is in Ericksons developmental stage of Ego Integrity
vs. Despair. Ego Integrity
refers as an older adult individual that is able to look at their life with successful or failure. On the contrast, a life
of
despair means an individual believes its entire life was a failure, they are not happy with the choices theyve made

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to
your determination:
-I feel that my patient is currently on the stage of Ego integrity because of her age (86 y/o) which it
means that she can look back into
her life and she sees her successes and was able to answered my all my questions without feeling depressed or
extremely
sad. Patient also spoke about her daughter followed her steps and became a nurse and worked in the same hospital
she did.
she was able to speak about her past and present with unequivocal pride.

Describe what impact of disease/condition or hospitalization has had on your patients developmental
stage of life:
-Patient complained about not being able to be more active and that she also had to give up the right of driving.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
-Patient states that illness might be due to genetics
What does your illness mean to you?
-Patients says that she does not longer do what she wants to do; its hard to give your activities as your age
increases.

+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? MALE
Are you aware of ever having a sexually transmitted infection? YES, I HAVE NEVER HAD AN STD
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? N/A
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? PILLS, CONDOMS
How long have you been with your current partner? 63 years (Husband expired a year an a half ago)
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? - N/A

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? Is very important
Do your religious beliefs influence your current condition? Patient believes that her religious beliefs influence
positively her condition
+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 last 3 days

Yes
No
For how many years? 20 years
(age: 18 thru: 38)

If applicable, when did the

patient quit? @ 38 years of age

Pack Years: 120 approx.

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? Stop smoking

2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?

Yes

No
For how many years?
(age

thru

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
- Patient was exposed to any of a nursing environmental hazards for over forty-three
5. For Veterans: Have you had any kind of service related exposure?

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? Patient states I feel overall in good health, I have always been active and
I will continue to be that way
Integumentary: Patient denies issues of hives, psoriasis, skin rashes, nails, or any other issues
HEENT: Patient requires glasses to see, denies a hx of cataracts, glaucoma, confirms some hearing loss
although she can not use hearing aids (per her primary care physician) , denies post-nasal drip, nose bleeds,
oral infection and dental problems.
Pulmonary: Patient denies asthma, bronchitis, emphysema, pneumonia, tuberculosis, and allergies
Cardiovascular: Patient has hx of atrial fibrillation, denies any other heart and vascular problems
GI: Patient denies hx of nausea, vomiting, diarrhea, constipations, IBS and other GI issues
GU: Denies any issues
Women/Men Only: Patient states had a hysterectomy
Musculoskeletal: Denies any issues
Immunologic: Denies any issues
Hematologic/Oncologic: Her blood type is A+, denies any issues
Metabolic/Endocrine: Denies any issues
Central Nervous System: Denies any issues
Mental Illness: Denies any issues
Childhood Diseases: Patient describe childhood as normal and having the regular season flus and such.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
- N/A

Any other questions or comments that your patient would like you to know?
- N/A

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General survey: The patient is an overweight, well-kept, not in distress, energetic, older woman
Pulse: 92
Blood Pressure (include location): L arm 144/103
Temperature (route taken): 97.7 orally
Respirations: 24
SpO2: 97 %
Room Air or O2: Room
Overall Appearance: Hair combed, clean, dress appropriate, maintains eye contact, patients is using non-skit socks
Overall Behavior: Calm, relaxed, judgment intact, interact well with others, awake
Speech: Crisp diction, clean
Mood and Affect: Pleasant, cooperative, cheerful, talkative
Integumentary: skin turgor elastic, no rashes, lesions, or deformities, nails without clubbing, capillary refill 3 seconds, hair
evenly distributed, clean, without vermin
IV Access: No redness, edema or discharge
HEENT: Facial features symmetric, no pain in sinus region, no pain, clicking of TMJ, trachea midline. Thyroid not
enlarged. No palpable lymph node. Sclera, white and conjunctiva clear, without discharge. Eyebrows, eyelids, orbital area,
eyelashes, and lacrimal glands symmetric without edema or tenderness. PERRLA pupil size 3 mm, peripheral vision intact.
EOM intact through 6 cardinal fields without nystagmus. Ears symmetric without lesions or discharge. Nose without lesions
or discharge. Lips, buccal mucosa, floor of mouth, and tongue pink and moist without lesions. Dentition white teeth and
intact
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. Percussion resonant throughout all lung fields, dull towards
posterior bases. Tactile fremitus equal without overt vibration
Cardiovascular: No lifts, heaves, or thrills. PMI felt at 5th intercostal midclavicular line. Heart sounds: S1 S2 were regular.
No murmurs, clicks or adventitious hearts sounds were present. No JVD. Pulses bilaterally equal (Apical:3+, Carotid: 3+,
Brachial:3+, Radial: 3+, DP: 3+). No temporal or carotid bruits. Edema: +2 (3-4mm) low extremities bilaterally.
Extremities warm with capillary refill less than 3 seconds.
GI:/GU: Bowel sounds active x4 quadrants; no bruits auscultated. Percussion dull over liver, spleen, over stomach, and
intestine. Abdomen non-tender to palpitation. Urine output: clear. Color: light yellow. Bathroom privileges: without
assistant. CVA punch without rebound tenderness. Last BM: 01/Nov/15, Formed, Soft. Color: light brown. Genitelia: No
assessed, patient alerted and oriented, denies problems.
Musculoskeletal: Full ROM intact in all extremities without crepitus. Strength bilaterally UE equal at 4, LE equal at 4.
Vertebral column without kyphosis or scoliosis. Neurovascular status intact: peripheral pulses palpable, no pain, pallor,
paralysis, or paresthesia.
Neurological: Patient awake, Alerted and Oriented x4. CN 2-12 grossly intact. Sensation intact to touch, pain, pain, and
vibration. Gait smooth, regular with symmetric length of the stride. Stereognosis, graphesthesia, and proprioception intact.
DTR: Triceps: +2, Biceps: +2, Brachioradial: +2, Patellar: +2, Achilles: +2, Babinski: 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):
Blood tests were performed every day. These labs were done on 03Nov15. X-Rays and ECG (12 leads) were
done on the 01Nov15.
WBC: 7.87 (3.5-10.5 Billion cells/L)
Cardiac Profile
RBC: 3.94 (3.90-5.03)
CPK: 47
HGB: 11.6 (12-15.5 grams/dL)
CK MB: 1.3
Sodium: 138 (135-145 mmmol/L)
CK MB Relative Inex: 2.8
Potassium: 3.6 (3.5-5.0 mEq/L)
Troponin I: <0.010
XR Chest PA & Lateral: Opacity partially cheers the R heart border consistent with R lobe airspace disease or
infiltrate. These appear to be a trace R effusion as well. Hyperinflation. Results: L lung is clear; Atherosclerotre
change of the aorta are noted.
ECG (12 lead): Atrial fibrillation with rapid ventricular response. Moderate T-wave abnormality, consider
University of South Florida College of Nursing Revision September 2014
10

lateral ischemia. Abnormal ECG. Possible ischemia now present, Sinus rhythm no longer present, T-wave
abnormality still present.

The PT presents with balanced WBC which indicates that she does not have any infection at the moment. On
contrast, low level of RBC and HGB could possibly indicates anemia. Regular level of sodium is congruent with
PTs diet. Level of Potassium although within range it could be a bit low. PTs cardiac profile is found within the
range that is considered regular. The X-Ray results conquered with PTs Chief complaint and PTs feeling of
irregularity with her heart.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
- Patient is currently working with USFs Cardiologist to get a better diet and maybe change some medications to
better control her atrial fibrillation

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

1. Decreased Cardiac Output r/t altered electrical conduction (Ackley, B. & Ladwig, G. 2014)
2.
3.
4.
5.

University of South Florida College of Nursing Revision September 2014

11

 15 CARE PLAN
Nursing Diagnosis: Decreased Cardiac Output r/t altered electrical conduction (Ackley, B. & Ladwig, G. 2014)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
Patient will have adequate cardiac
1. Serve only small, frequent,
1. Clients with cardiac disease do
output
sodium-restricted, low saturated fat better with small meals due to less
meals
work on the heart to digest those
small meals
2. Assess for presence of anxiety
2. Clients with depression have
and refer to treatment
high morbidity rates
3. Observe for syncope, dizziness,
3. Dysrhythmias, especially Atrial
palpitations of feeling of weakness fibrillation are common in clients
associated with irregular heart
with heart failure.
beats
4. Observe for side effects from
4. Elderly clients have a hard time
cardiac medications
metabolizing and excreting
medications due to decrease liver
and kidney functions
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
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

12

 15 CARE PLAN
Patient Goals/Outcomes
Patient will remain without falls
During her stay in the hospital

Nursing Diagnosis: Risk for falls (Ackley, B. & Ladwig, G. 2014)

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
1. Complete a fall-risk assessment
1.The tool screens for primary
for older adults using a valid and
prevention of falls
reliable tool
2. Screen all clients for balance and 2. It is helpful to obtain the
mobility skills
functionalities of the patient to
determined method to ensure safety
3. Teach method to decrease
3. Watch the patient closely for
dizziness
dizziness during increase activity

Evaluation of Goal on Day Care

is Provided

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
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

13

References
Pathophysiology. (2008). Atrial Fibrillation Teaching File. University of Toronto. Retrieved from
http://afib.utorontoeit.com/pathophysiology.html
Atrial fibrillation. (2014). Atrial Fibrillation. Mayo Clinic. Retrieved, from
http://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/basics/definition/con20027014
Case-Lo, C. (2013). Atrial Fibrillation: Whats My Prognosis?. Heathline.com. Retrieved from
http://www.healthline.com/health-slideshow/atrial-fibrillation-prognosis#2
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, Mo.: Elsevier.

University of South Florida College of Nursing Revision September 2014

14