UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Tatyana Boytsan

Assignment Date: 07/02/15
.
1 PATIENT INFORMATION Agency: SMH
Patient Initials: L. G. Age: 85 Admission Date: 06/30/2015
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: Unstable Angina
Primary Language: English
Level of Education: High School Diploma Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Dental Office Manager Patient indicated NSTEMI, but has had it before.
Number/ages children/siblings:
Three children: ages 62, 63, 64
Served/Veteran: Code Status: Full Code
If yes: Ever deployed? Yes or No
Living Arrangements: Patient lives by herself in her home in Advanced Directives: No
Sarasota. If no, do they want to fill them out? No
Surgery Date: 07/01/15 Procedure: Stent
placed
Culture/ Ethnicity /Nationality: American
Religion: Christian/Baptist Type of Insurance: Blue Cross Blue Shield

1 CHIEF COMPLAINT:
I started having this pressure and pain in the middle of my chest, and it felt like it was going up to the right side of my
jaw.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient woke up on the morning of admission, 6/30/2015, with mid-chest pressure and slight sharp pain. Patient
indicated that there was also right sided jaw discomfort. The pain and pressure did not worsen with exertion or improve
with rest, which is when the patient went to the emergency room. Patient was given nitropaste and two single sublingual
nitroglycerin and an hour later patient indicated that she no longer felt the pressure or pain. The next day, 07/01/2015, the
patient went into surgery to get a drug-eluting stent placed. The patient was then discharged the afternoon of 07/02/2015.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
July of 1947 Tonsillectomy
November of 1960 Hysterectomy
May of 2013 First cardiac stent (drug-eluting stent placement to the mid-circumflex)
August of 2014 Diagnosed with mild COPD, mild to moderate aortic stenosis, obesity, and diabetes. // Treatments
include lifestyle changes and medications include Cozaar 50mg and Metformin 1000mg.
January of 2015 Diagnosed with Non-ST Segment Myocardial Infarction (NSTEMI) // treatment: antiplatelet therapy
and anticoagulant therapy, medications include Lipitor 40mg, Plavix 75mg, and Coreg 12.5 mg
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma
Cause

Cancer

Problems

Tumor
Stroke
Allergies

MI, DVT
Gout
MEDICAL of

Mental
Heart
HISTORY Death

(angina,
(if
applicable)
Uncontroll
Father 88 X X
ed Diabetes
Heart
Mother 88 X
Attack X
N/
Brother
A
N/
Sister
A
Maternal Grandma Heart
88 X X X
Attack
Paternal Grandpa Cerebral
59 Hemmorag X
X
e
relationship

Comments: Include age of onset

Patient does not know, or remember, the age of onset regarding the medical history of her family, she only remembers what medical
issues they had.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) X
Adult Tetanus (Date) Is within 10 years? X
Influenza (flu) (Date) Is within 1 years? X
Pneumococcal (pneumonia) (Date) Is within 5 years? X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
University of South Florida College of Nursing Revision September 2014 2
 If yes: give date, can state U for the patient not knowing date received

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Penicillin Erythematous urticaria all over the skin
Medications

Wheat GI upset, cramps and occasionally diarrhea

Other (food, tape, Seasonal Allergies Dry cough, runny nose, and scratchy throat
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)

Unstable angina is a form of acute coronary syndrome that results from reversible myocardial ischemia. (Huether &
McCance, 2012, p.604) Unstable angina occurs when atherosclerotic plaque either ruptures, or theres thrombosis, and
there is a partial obstruction of the coronary blood flow. At this point, within twenty minutes or less, transient ischemia
occurs which is what actually leads to the unstable angina. A patient can tell they have angina if they have sharp chest
pain, however accompanying this sometimes is dyspnea, anxiety, tachycardia, and perspiration. For a more objective way
of diagnosing, an ECG may be done, which would show depression of the ST segment and T wave inversion. Lab values
of troponins, CPK-MB, and LDH1 may also be viewed. When unstable angina occurs, it is important to seek treatment
immediately as this may indicate that a myocardial infarction may occur soon. Treatment includes immediate
hospitalization with oxygen delivery, nitrates, aspirin, and analgesics. Beta-blockers, ACE inhibitors, and other
anticoagulants may be given. (Huether & McCance, 2012)

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 Aspirin Concentration Dosage Amount 325mg

Route Oral Frequency PO Daily

Pharmaceutical class NSAID/Anticoagulant Home Hospital or Both
Indication Used to reduce blood clots, and as an anti-inflammatory.
Adverse/ Side effects Heartburn, nausea, GI distress, peptic ulcer, and bleeding.
Nursing considerations/ Patient Teaching Monitor serum salicylate level (therapeutic is 15-30mg/dL). Careful with other anticoagulants, and foods containing
salicylates (i.e. prunes, raisins, and licorice).

Name Atorvastatin (Lipitor) Concentration Dosage Amount 40mg

Route Oral Frequency PO QHS

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Pharmaceutical class Statin Home Hospital or Both
Indication Decrease LDL, lower high cholesterol.
Adverse/ Side effects Constipation, abdominal cramps, and liver impairment
Nursing considerations/ Patient Teaching Patient will need blood tests for liver function. Medication needs to be taken at bedtime.

Name Carvedilol (Coreg) Concentration Dosage Amount 125mg

Route Oral Frequency PO BID

Pharmaceutical class Beta Blocker Home Hospital or Both
Indication Treats high blood pressure and CHF.
Adverse/ Side effects Dizziness, insomnia, lethargy, shortness of breath, bradycardia, and edema. Can affect diabetic patients blood glucose levels.
Nursing considerations/ Patient Teaching Avoid orthostatic hypotension, do not discontinue suddenly, and check heart rate and blood pressure (both the nurse and make
sure the patient can check it herself when she is at home).

Name Clopidogrel (Plavix) Concentration Dosage Amount 75mg

Route Oral Frequency PO Daily

Pharmaceutical class Antiplatelet Drugs Home Hospital or Both
Indication Blocks platelet aggregation, blood thinner that can be used to prevent further cardiac issues.
Adverse/ Side effects Bleeding, stomach pain, loss of appetite, diarrhea, rash/itching, hemorrhage, and salicylate poisoning.
Nursing considerations/ Patient Teaching Monitor serum salicylate levels (especially since patient also takes Aspirin). Careful not to get injured, as lots of bleeding may
occur.

Name Levothyroxine (Synthroid/Levoxyl) Concentration Dosage Amount 100mg

Route Oral Frequency PO AC

Pharmaceutical class Synthetic T4 Home Hospital or Both
Indication Treats hypothyroidism
Adverse/ Side effects Hyperthyroidism, fever, insomnia, tachycardia
Nursing considerations/ Patient Teaching: Patient should take 30 minutes before breakfast, nurse should not hold for tube feedings.

Name Losartan (Cozaar) Concentration Dosage Amount 50mg

Route Oral Frequency PO BID

Pharmaceutical class ARBs Home Hospital or Both
Indication Treats high blood pressure, and reduces the risk of stroke.
Adverse/ Side effects Hypotension, hyperkalemia, headache, swelling, fever or chills.
Nursing considerations/ Patient Teaching Take drug at the same time every day, avoid alcohol, and avoid salt substitutes.

Name Metformin (Glucophage) Concentration Dosage Amount 1,000mg

Route Oral Frequency PO BID

Pharmaceutical class Biguanide Home Hospital or Both
Indication Treats Type 2 Diabetes Mellitus
Adverse/ Side effects Nausea/Vomiting, metallic taste in the mouth, stomach upset, diarrhea, and weakness.
Nursing considerations/ Patient Teaching: Take with meals. Hold if serum creatinine is greater than or equal to 1.4 mg/dl (female) or 1.5 mg/dl (males). Stop 48 hours
before using iodinated contrast media.

Name Sitagliptin (Januvia) Concentration Dosage Amount 100mg

Route Oral Frequency PO Daily

Pharmaceutical class Dipeptidyl peptidase-4 inhibitor Home Hospital or Both
Indication Treats Type 2 Diabetes by helping control high blood sugar.
Adverse/ Side effects Oliguria, pancreatitis, swelling, shortness of breath
Nursing considerations/ Patient Teaching Monitor side effects when patient is also on insulin, or if patient is on digoxin.

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Name Acetaminophen (Tylenol) Concentration Dosage Amount 650mg

Route Oral Frequency PO Q4H PRN

Pharmaceutical class Analgesic/Antipyretic Home Hospital or Both
Indication Give to patient for mild pain or temperature rising above 101 degrees Fahrenheit
Adverse/ Side effects Nausea, upper stomach pain, loss of appetite, dark urine, jaundice
Nursing considerations/ Patient Teaching Overdose can cause necrosis of the liver. Patient should avoid alcohol. Administer with full glass of water, and can be taken
with or without food.

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 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Normal Diet Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Gluten Free Consider co-morbidities and cultural considerations):
24 HR average home diet: Patient eats around a 2000 calorie diet, however around 400
calories are empty calories. Since the patient is diabetic it
would be good for her to consume more whole grains. But
the patient consumes little to no grains at all, while
consuming twice as much protein as needed in a day.
Patient consumes a healthy amount of fruits and veggies,
however she only consumes around 50% of the amount of
dairy she needs. She also slightly overconsumes the amount
of oils, saturated fats, and sodium that she should be
consuming. Overall she has a mostly healthy diet but since
she does have cardiac problems she needs to work on
lowering her sodium and (slightly lowering) protein intake.
Breakfast: 2 boiled eggs and bacon.

Lunch: Broccoli (1/2 cup), green beans (1.5 cup), celery

(1/2 cup), almonds (1/2 cup), and a medium apple.
Occasionally a protein shake instead.
Dinner: Sweet potatoes (1 cup, usually mashed) and pork
chops (around 2 servings).

Snacks: Fruits, yogurt, chocolate, donuts, crackers with

hummus. (Usually one healthy option and one junk food
option a day)

Liquids (include alcohol): Pomegranate juice, water, and

coffee (with a cup of whole milk and 2 teaspoons of
sugar).

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?
Patient indicates that her daughter, who is a nurse, helps her when she is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient indicates that she uses laughter as a way to cope with stressful or upsetting situations, for example she reads jokes
and watches funny videos. Patient also indicates that she uses her faith in Christ as a coping mechanism, for example
prayer.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient states I have been feeling anxious about my heart lately, but it usually goes away with prayer.

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+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? ______________________

Are you currently in a safe relationship? Yes

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion 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:
Ego integrity is when the person has peace with where they are near the end of life and feel satisfied that they have lived a fulfilling
life. Despair is when the person fears dying and does not feel like they are ready to go yet; this is when the person is not comfortable
with where they are in life and desperately desire to go back in time or have more time in their life. (Treas & Wilkinson, 2014)

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient is in the Ego Integrity stage. This is evidenced by how the patient carries herself and how she speaks about
life. She is very cheery and upbeat, joking around and smiling warmly. She indicated that she realized that she is getting
old and that she cannot do as much as she used to for her children but that it doesnt take away from all that she has done
for them throughout her life. Right after, she states there is a time and season for all things, and this is just the start of a
new season for me.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
It has just made the patient realize exactly what kind of health level she has so that she knows her limitations in what she
can or cannot currently do in this stage of her life. The hospitalization, including the stent placement, has shown the
patient that she needs to continue taking her medications and her health condition seriously otherwise she wont just be
nearing death, but could possibly die.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states her wild living is the cause. She indicated that she used to drink and smoke quite a bit when she was
younger.

What does your illness mean to you?

Patient states I cant do everything that I want to, so it limits me to some of the things I want to do.

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+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? ______________No___________ If yes, are you in a monogamous relationship?
_________No_________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? __N/A__________________

How long have you been with your current partner?_______________49 years with ex-husband_____________

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

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient indicated that religion is very important to her, that she grew up Christian and her whole life revolves around it. ____
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
Yes, patient states it is what helps me get through it and stay strong. _____________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? Cigarettes How much?(specify daily amount) For how many years? 22 years
pack daily (9 years), 1 pack daily
(8 years), then 2 pack daily (5 (age 27 thru 49 )
years)

If applicable, when did the

Pack Years: 16
patient quit?
1979, at 49 years old
Has the patient ever tried to quit? Yes
Does anyone in the patients household smoke tobacco? If
If yes, what did they use to try to quit? Cold turkey,
so, what, and how much? No one
with prayer.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? For how many years?
Volume: 2oz hard liquor, one glass
Beer, wine, bourbon. (age 25 thru 45 )
of wine, pitcher of beer.
Frequency: Socially, on weekends,
for 20 years. Usually one to two
servings.
If applicable, when did the patient quit?
At 45 years old, 1975

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 thru )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No

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

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

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? Patient states I know that I am not very healthy, but I do okay.

Integumentary: Patient has Psoriasis for five years now. She bathes every third day. She denies using
sunscreen, as she indicates that she does not go out into the sun often. She denies problems with her nails,
dandruff, rashes, or skin infections.
HEENT: Patient has hearing aids for three years now and denies ear infections. She has been wearing glasses
for 40 years now, and goes to the optometrist once a year. She denies having cataracts or Glaucoma. She brushes
her teeth twice a day, goes to the dentist for routine visits twice a year, and denies dental problems. She has
sleep apnea and a tonsillectomy at 17 years old; otherwise denies nasal and oral/pharyngeal problems.
Pulmonary: Patient has difficulty breathing when she is in contact with allergens like spores or dust. Patient
also has mild COPD. She denies coughing, asthma, bronchitis, pneumonia, tuberculosis. Last CXR was done in
the hospital on 07/01/15.
Cardiovascular: Patient has hypertension, and angina upon admission. Patient had a thrombus before but does
not remember much about it. Patient denies hyperlipidemia, MI, PVD, CHF, murmurs, rheumatic fever,
myocarditis, and arrhythmias. Last EKG was done upon admission on 06/30/15.
GI: Patient has had GERD for three years now, and all the symptoms that come with it (nausea, vomiting,
indigestion, and heart burn). Patient denies having hemorrhoids, yellow jaundice, pancreatitis, colitis,
diverticulitis, appendicitis, abdominal abscess, irritable bowel disease, cholecystitis, ulcer, blood in her stool,
and hepatitis. Patient denies having common bouts of diarrhea or constipation.
GU: Patient indicates that she urinates five to six times a day, usually. She denies nocturia, dysuria, hematuria,
polyuria, kidney stones, and bladder or kidney infections.
Women/Men Only: Patient denies ever having an infection of her genitalia. Patient denies monthly self-breast
exams, indicates that she does them every three months. Patient does not remember the last time she had a
pap/pelvic exam or mammogram, or her last gyn exam; she states it has probably been years. Patient indicates
that she had her first menarche at 14, and started menopause at 54; she no longer has a menstrual cycle. Patient
doesnt think she has ever done a DEXA bone density test.
Musculoskeletal: Patient had a broken ankle around 66 years old because she fell and was in a wheelchair for
three months. Patient has arthritis since she was 64. She denies any pain, weakness, gout, or osteomyelitis.

University of South Florida College of Nursing Revision September 2014 10

Immunologic: Patient denies ever having chills with severe shaking, night sweats, HIV/AIDs, Lupus,
rheumatoid arthritis, sarcoidosis, or tumors. Patient denies ever having a life threatening allergic reaction.
Patient sometimes had enlarged lymph nodes when she gets sick, accompanied by a fever.
Hematologic/Oncologic: Patient denies anemia, bleeding or bruising easily, cancer, or blood transfusions.
Metabolic/Endocrine: Patient has hypothyroidism for around 10 years now and Type 2 Diabetes for about 15
years, she doesnt remember how long exactly. She denies intolerance to hot or cold and osteoporosis.
Central Nervous System:
Mental Illness: Patient sometimes has anxiety about stressful situations, which include health concerns relating
herself. Otherwise patient denies depression, schizophrenia, and bipolar disease.
Childhood Diseases: Patient denies measles, mumps, polio, scarlet fever, and chicken pox.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient indicated that she has had gallbladder attacks at least ten times but has only seen her primary care provider
about it, and never got her gallbladder removed.

Any other questions or comments that your patient would like you to know?
Patient indicated that there isnt anything else she could think of.

10 PHYSICAL EXAMINATION:
General survey ______Patient is an 85 y/o female who is alert and oriented x3.________________
Height __53______Weight___213____ BMI ___37.76____ Pain (include rating and location)_____0____________
Pulse__69___ Blood Pressure (include location)_Peripheral, 146/61______Temperature (route taken)_97.8F oral__
Respirations_____18_____ SpO2 ______96%________ Room Air or O2__Room Air_____________
Overall Appearance_____Calm, not in distress, and not in pain. Patient is dressed well and acting correctly in relation to
the situation and hospital setting._
Overall Behavior___Patient is awake, relaxed and upbeat____________________________________________________
University of South Florida College of Nursing Revision September 2014 11
Speech_Patients speech is clear and articulate_________________________________________________________
Mood and Affect_Patient is pleasant, cheerful, and talkative. __________________________________
Integumentary__Skin is warm, dry, and intact. Skin turgor is elastic. There are no rashes, lesions, or skin deformities.
Patients nails have no clubbing, and a capillary refill of two seconds. Her hair is evenly distributed, clean, and looks
healthy.
IV Access_No IV access_________________________________________________________________________
HEENT_Patient has full facial symmetry with no edema. Patient denies any pain. Mucous membranes are pink and moist
without any lesions. Sclera is white and conjunctiva clear. Pupils are equal, round, reactive to light, and accommodate.
EOM intact through 6 cardinal fields without nystagmus. Patient passed whisper test. Overall, no abnormalities._______
Pulmonary/Thorax_Respirations are regular and unlabored; lung sounds are clear in each lobe, slightly diminished toward
posterior bases. Transverse to AP ratio is 2:1. There is symmetric chest expansion in the patient. There is no sputum
production._____________
Cardiovascular__No thrills were auscultated. S1 and S2 are audible and regular. There are no murmurs, or other
adventitious heart sounds. No jugular vein distention._____________________________________
GI___Bowel sounds are active in all four quadrants and no bruits were auscultated. Abdomen is rounded but non-tender to
palpitation. Percussion was dull over liver and spleen and tympanic over stomach and intestine. Last bowel movement for
that patient was this morning, which is normal for her. It was semi-formed, and medium brown. Patient denies any GI upset
or pain, and nausea.__________
GU_Urine is clear and light yellow. Patient has a total output of 1,100mL of urine within the last 24 fours. _______
Musculoskeletal___Patient has full range of motion in all extremities without crepitus. Strength is a 5/5 equally and
bilaterally in all extremities. Patients spine is without kyphosis or scoliosis. _________________________________
Neurological Patient is awake, alert, and oriented to person, place, and time or date. Her cranial nerves are grossly intact.
Patient has sensation to touch and pain. Patient is Romberg negative. Gait is smooth, regular with symmetric length of
stride. Stereognosis, graphesthesia, and proprioception is intact.

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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis

Potassium Upon admit, the patients Potassium is an electrolyte
potassium level was in the that is related to/involved
4.3 6/30/2015 09:25 normal range. However, with muscle control, nerve
3.6 L 7/02/2015 04:41 potassium levels started to function, and blood
trend downwards indicating pressure. Low potassium
the onset of hypokalemia. can weakness in these
Norm (3.7-5.4 mmol/L) functions.
Troponin Upon admit, patient already Protein in the blood that is
0.09 H 6/30/2015 13:56 had slightly higher troponin released if heart muscle
0.32 H 6/30/2015 20:43 levels. They then started damage has occurred. High
0.55 H 7/01/2015 06:13 trending upward, likely levels of troponin mean a
indicating minor myocardial heart attack has occurred or
0.79 H 7/02/2015 04:41
injury. patient is at high risk for a
Norm (0.00-0.05ng/mL) heart attack.
CPK-MB No trend available as this This isoenzyme is usually
was only checked one time, only found in the
3.7 H 6/30/2015 09:25 and this is the only value myocardium, and if elevated
given, but it is important to as the lab indicates, this
University of South Florida College of Nursing Revision September 2014 12
 Norm (0.0-3.6 ng/mL) note that it is elevated. means injury occurred to the
myocardial cell wall.
Sodium No trend available as this Sodium is a
lab value was only taken mineral/electrolyte that if
142 06/30/2015 09:25 once, and this is the only elevated may indicate
value available although hypertension and
cardiovascular disease.
Norm (131-145 mmol/L) it is in the normal range.
Patients sodium level is
within the normal range.
Glucose No trend available as this Glucose is a sugar and
was only checked the one high values of blood
122 H 06/30/2015 09:25 time, at which point it glucose is indicative of
was elevated. Diabetes, which the
Norm (60-100mg) patient has (Type 2).

+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 on a normal diet. Every four hours vitals are taken. There is a consult with the cardiologist set
up for a week from her discharge date. An EKG was done while the patient was in the hospital. Labs are done and
trends recorded daily, one specifically monitored is the troponin levels since the heart muscle may have been
damaged. A chest x-ray was also done, which showed a normal cardiac silhouette and sclerotic density in the left
proximal humerus, and possible enchondroma, but otherwise no acute bone on bone changes. Left heart
catheterization, coronary angiography and percutaneous coronary intervention of the distal RCA also was done
on 07/01/2015.

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

1. Acute pain r/t myocardial tissue damage from inadequate blood supply as evidenced by unstable angina, troponin
lab values, and CPK-MB lab values.

2. Risk for decreased cardiac tissue perfusion r/t possible restenosis.

University of South Florida College of Nursing Revision September 2014 13

 15 CARE PLAN
Nursing Diagnosis: Acute pain r/t myocardial tissue damage from inadequate blood supply as evidenced by unstable angina, troponin lab values,
and CPK-MB lab values
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will be free of chest pain Assess pain levels by self-report Self-report is the considered to be Goal was met, patients pain level
for 12 hours as evidenced by a zero from the patient and observe the the most reliable way of knowing if was a two earlier in the morning
on the 0-10 pain scale. patient for any behavior indicative the patient is in pain and how but then a zero to ten pain scale for
of pain (i.e. grimacing or intense it is. (Ackley & Ladwig, the rest of the day.
moaning). Provide comfort 2014) Proving comfort,
measures for the patient. If there is medications, and non-
pain, depending on what the patient pharmacological methods not only
prefers, provide pharmacological decrease pain levels but give the
and non-pharmacological methods patient the option of how she
to reduce pain. would prefer decreasing it.
Patient will be free of chest pain Develop a treatment plan with the Involving the patients caretaker, Goal/Outcome cannot yet be
when she is out of the hospital and patient and her caretaker (her her daughter, in creating a pain assessed.
at home. daughter). Provide the patient and management plan outside of the
daughter with written material on hospital ensures that the patient
controlling pain that includes how will be accountable toward
to use a pain rating scale and how managing her pain, and is helpful
to take pain medication. Sit down in case the patient ever forgets how
and go over how the patient to do so. Written material is a good
manages her pain at home, and idea because it is something
have her set up a goal number on tangible they can take home to look
the pain scale so if it goes above it back on. Going over the
she may take action to decrease her medication list ensures that the
pain. Go over the list of patient wont end up hurt by drug
medications she takes (including interactions. This also opens up
herbals and OCT) to ensure that communication and gives the
there are no drug interactions with patient or caretaker an opportunity
her analgesics and other to bring up any new medication
medications. they might want to try which you
can ensure that it can be therapeutic
and not harmful (side effects, drug
interactions, food interactions).
University of South Florida College of Nursing Revision September 2014 14
Patient will learn about non-
pharmacologic methods of
decreasing pain.
Written material may be given on
this, but the nurse needs to also sit
down and discuss or show some of
the methods that the patient can use
to manage her pain inside and
outside of the hospital.
Pain medication is used to decrease Met! Patient was aware of old
pain however the patient would wives tales on how to deal with
like to know, if possible, pain, but now has a deeper
therapeutic alternative ways of understanding of what she can do
dealing with her pain. This is good that doesnt involve medication to
knowledge for the patient to know, ease her pain.
and eases her mind with a possible
chance of not taking as many
medications as she indicated that
she has gotten a bit sick of having
to take so many.

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
XF/U appointments
XMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes X No
Rehab/ HH
Palliative Care
X Post Cardiac Discharge Instructions
Patient is being discharged to her home, in which her daughter will care for her if needed. Patient has all the skills and materials necessary to
successfully be at home and take care of herself.

University of South Florida College of Nursing Revision September 2014 15

 References

Ackley, B.J., & Ladwig, G.B. (2014) Nursing Diagnosis Handbook: An Evidenced-Based Guide to Planning Care (10th Ed.) Maryland Heights,

Missouri: Mosby Elsevier.

Food Tracker: (n.d.) Retrieved July 14, 2015, from https://www.supertracker.usda.gov/

Huether, S. E., & McCance, K. L. (2012) Understanding Pathophysiology (5th Ed) St. Louis, Missouri: Mosby Elsevier.

Treas, L. S., & Wilkinson, J. M. (2014) Basic Nursing: Concepts, Skills, & Reasoning. Philadelphia, Pennsylvania: F.A. Davis Company

Unbound Medicine, Inc. (2015) Daviss Drug guide (Version 1.17) [Mobile application software]. Retrieved from

https://itunes.apple.com/us/app/daviss-drug-guide-updates/id301427093?ml=8

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