UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Michael Cook

MSI & MSII PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 3-20-2016

Agency: MPM

Patient Initials: R.W.

Age: 84

Admission Date: 2-15-2016

Gender: Male

Marital Status: Married

Primary Medical Diagnosis Cong. Heart Failure

Primary Language: English

Chronic Kidney Disease, SOB, A Fib., UTI

Level of Education: Bachelors Degree

Other Medical Diagnoses: Valvular Disease

Occupation: Civil Engineer

Cardiomyopathy, CAD, Hyperlipidemia

Number/ages children/siblings: 2 daughters (60 yo., 58 yo.)

Benign Prostatic Hyperplasia

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

Code Status: Full Code

Living Arrangements: Lives with wife who is fully mobile and

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: N/A
Procedure: CXR, EKG

active, house has no stairs

Culture/ Ethnicity /Nationality: Non-hispanic White
Religion: Presbyterian

Type of Insurance: Medicare, Blue Cross Blue

Shield

1 CHIEF COMPLAINT:
It was becoming difficult to breathe and I thought I may have gotten an infection from the self-catherizing, even though
I was doing everything I was told.

3 HISTORY OF PRESENT ILLNESS:

Patient started noticing shortness of breath the day before admission, as well as an unpleasant sensation in his urethra
Following several days of self-catheterization for urinary retention. The shortness of breath was constant throughout the
Day but was more pronounced when laying flat. The pain in the urethra was classified as a slight stinging pain and so
The patient communicated with his primary before being sent to the hospital. Along with the shortness of breath, the
Patient noted acute swelling in the ankles and was worried about the sudden onset of the edema. The patient did not
Report any treatments that successfully alleviated the shortness of breath or edema, or urinary irritation. The urethral
Discomfort was rated as a 4/10.

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
4/10/2013

Operation or Illness

Daughter

58

N/A

Tumor

N/A

Stroke

60

Stomach Ulcers

Daughter

Seizures

UK Cirrhosis

Mental
Problems
Health

Grandfather

Kidney Problems

80s Cancer

Hypertension

Grandmother

Gout

M.I.

(angina,
MI, DVT
etc.)
Heart
Trouble

52

Glaucoma

Brother

Diabetes

Cancer

Cancer

76

Bleeds Easily

Mother

Asthma

63

Arthritis

Father

Cause
of
Death
(if
applicable)
M.I.

Anemia

2
FAMILY
MEDICAL
HISTORY

Age (in years)

~ 2010

Environmental
Allergies

2/27/2007

Alcoholism

Coronary stent
Inguinal hernia repair
Back surgery
Aortic valve replacement
Pacemaker and internal cardioverter/defibrillator implantation
Benign prostatic hyperplasia
Upper respiratory tract infection (viral)
Respiratory alteration
Cardiovascular alteration
Transient ischemic attack

Comments:

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria 7/17/2015
Adult Tetanus
Influenza (flu) 10/2015
Pneumococcal (pneumonia) 2/8/2015
Have you had any other vaccines given for international travel or
occupational purposes?

YES

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

Type of Reaction (describe explicitly)

Rash, itching

Medications

No known food allergies

No known tape allergies
No known latex allergies
No known envir. allergies

Other

5 PATHOPHYSIOLOGY:
As a consequence of chronic, poorly managed hypertension, the systemic vascular resistance of the body remains elevated and this
increased pressure puts a higher demand on the left side of the heart, in particular the left ventricle, in terms of contractility (Osborn,
Wraa, Watson, & Holleran, 2014). Over time, the heart muscle undergoes a stage of remodeling in which the cardiac muscle increases
in size and consequently gains an increased ability to further contract so as to overcome the systemic vascular resistance. However, the
enlarged cardiac muscle also occupies a larger space and this decreases the stroke volume by reducing the volume of the ventricular
chamber for filling (Huether & McCance, 2012). The ineffective compensation mechanism leads to a sustained inability for the heart
to pump effectively, reducing cardiac output as well as the bodies ability to properly circulate fluid to the renal system. The poorly
circulated fluid accumulates, typically in tissues in the periphery and often in the lower extremities as a consequence of gravitational
forces.
Huether, S. E.; & McCance, K.L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby.

Osborn, K.S., Wraa, C.E., Watson, A.B., & Holleran, R. (2014) Medical surgical nursing: Preparation for practice (2 nd
ed). Boston, MA: Pearson Education, Inc.

5 MEDICATIONS:
Name ertapenem (Invanz)

Concentration 1g/vial

Route IV

Dosage Amount 1g
Frequency q4hr

Pharmaceutical class anti-infectives

Home

Hospital

or

Both

Indication complicated urinary tract infections

Adverse/ Side effects seizures, pseudomembranous colitis, anaphylaxis
Nursing considerations/ Patient Teaching teach patient recognize signs and symptoms for adverse reactions such as rash, itching, swelling, severe abdominal pain,
and be aware of potential seizure activities and familiarize with precautions and interventions
Name finasteride (Proscar)

Concentration 5mg/tablet

Route PO

Dosage Amount 5mg

Frequency daily

Pharmaceutical class androgen inhibitors

Home

Hospital

or

Both

Indication benign prostatic hypertension

Adverse/ Side effects prostate cancer(high-grade), breast cancer, decreased libido, infertility and erectile dysfunction
Nursing considerations/ Patient Teaching teach patient about potential sexual side effects and about signs and symptoms for breast and prostate cancer

Name bumetanide (Bumex)

Concentration 1 mg / 4 mL

Dosage Amount 1 mg

University of South Florida College of Nursing Revision September 2014

Route IV inj

Frequency daily

Pharmaceutical class loop diuretic

Home

Hospital

or

Both

Indication edema due to heart failure

Adverse/ Side effects dehydration, hypokalemia, hypovolemia, hypocalcemia, hypomagnesemia, aplastic anemia, agranulocytosis, erythema multiforme
Nursing considerations/ Patient Teaching monitor electrolyte levels, monitor input and output, educate about orthostatic hypotension
Name carvedilol (Coreg)

Concentration 6.25 mg / tablet

Route PO

Dosage Amount 6.25 mg

Frequency 2x daily

Pharmaceutical class beta blocker

Home

Hospital

or

Both

Indication management of hypertension and heart failure

Adverse/ Side effects dizziness, cough, hypotension, angioedema, bradycardia, pulmonary edema
Nursing considerations/ Patient Teaching monitor for hypotension, monitor heart rate, monitor respiratory status for pulmonary edema, educate patient about orthostatic
hypotension, teach patient to report signs of angioedema
Name aspirin (Ecotrin)

Concentration 81 mg / tablet

Route PO

Dosage Amount 81 mg

Frequency daily

Pharmaceutical class salicylate

Home

Hospital

or

Both

Indication prophylaxis of transient ischemic attacks and myocardial infarction

Adverse/ Side effects gastrointestinal bleeding, dyspepsia, nausea, anaphylaxis and laryngeal edema
Nursing considerations/ Patient Teaching monitor for bleeding, educate patient to cease alcohol consumption, educate about signs and symptoms of G.I. bleeding
Name amiodarone

Concentration 100 mg / tablet

Route PO

Dosage Amount 100 mg

Frequency daily

Pharmaceutical class antiarrhythmics

Home

Hospital

or

Both

Indication atrial fibrillation

Adverse/ Side effects acute respiratory distress syndrome, pulmonary fibrosis, pulmonary toxicity, worsening of arrhythmias, toxic epidermal necrolysis
Nursing considerations/ Patient Teaching monitor vigilantly for signs of respiratory status changes, monitor heart monitor for worsening of atrial fibrillation, teach
patients to recognize and reports sign of worsening respiratory status or cardiac status
Name potassium chloride

Concentration 10 mEq / tablet

Route PO

Dosage Amount 10 mEq

Frequency daily

Pharmaceutical class mineral/electrolyte supplement

Home

Hospital

or

Both

Indication hypokalemia r/t diuretic use

Adverse/ Side effects arrhythmias, abdominal pain, diarrhea, nausea, vomiting, flatulence
Nursing considerations/ Patient Teaching monitor for dysrhythmias, monitor potassium levels, educate patient to report alterations in cardiac sensations
Name docusate (Colace)

Concentration 240 mg / tablet

Route PO

Dosage Amount 240 mg

Frequency daily

Pharmaceutical class stool softener

Home

Hospital

or

Both

Indication prevention of constipation

Adverse/ Side effects cramps, diarrhea, rashes, throat irritation
Nursing considerations/ Patient Teaching monitor bowel movement frequency, assess for abdominal distention, educate patient about increasing bulk-forming food
items in the diet

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION:
Diet ordered in hospital? Cardiac diet
Diet patient follows at home? No restrictions
24 HR average home diet:
Breakfast: glass of water (8 oz) and coffee (8 oz),
French Toast with pat of butter, three scrambled eggs
Lunch: bologna and cheese sandwich x 1.5, potato chips
(4 oz) Coffee (8 oz)
Dinner: meatloaf (8 oz), mashed potatoes (4 oz), brocolli
(2 oz), coca cola (8 oz)
Snacks: N/A

Analysis of Home Diet:

Although the patient is technically eating just within the
Recommended calorie limits for someone his size, he is far
Above the allotted saturated fat content, sugar content, and
He is more than doubling the allotted quantity of sodium
For the day, which serves to increase retained fluid volume.
This increase in volume is detrimental for patients with
Heart failure as it overloads the already weakned heart
Functionality. Furthermore, the patient reports eating no
Fruit whatsoever, which is not recommended.

Liquids (include alcohol): 1.5-2.0 L of water, 12 oz of beer

Choose My Plate. (2015, April 3). Nutritional analysis of 24
hour meal consumption. Retrieved February 19, 2016 from:
http://www.choosemyplate.gov/tools-supertracker

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
My wife usually. Occasionally my daughters come by as well, but they are a busy nowadays.
How do you generally cope with stress? or What do you do when you are upset?
I do some meditation and deep breathing exercises everyday.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Lately, deep breathing hasnt been helping as much so my wife and I are talking about Traditional Chinese Medicine.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? ________No.._____________________________
Have you ever been talked down to?No, I havent

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. Things have been pretty good. If yes, have you sought help for this? __N/A______

University of South Florida College of Nursing Revision September 2014

Are you currently in a safe relationship?

Absolutely..

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation
Ego Integrity vs.

In the Ego Integrity vs. Despair stage, an individual is often left in a position to reflect on what they have accomplished in their lives

and this reflection can either lead to a sense of accomplishment and success through ones perspective, or it can lead to
a dissatisfaction with the productivity of ones life leading to despair (Myers, 2009).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

The patient demonstrated qualities of this development stage in that he reflected happily on all of his accomplishments,
despite the difficulty of his position including: his professional career, his loving relationship and the health of his family.
Myers, D. G. (2009). Psychology (9th ed.). New York, NY: Worth Publishing Ltd.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

Despite the difficulty of his condition, the patient was very much satisfied with his life and accomplishments and was
dedicated optimistically to try Traditional Chinese Medicine with his wife so as to alleviate his condition. He was proud,
contented and seemingly resolved about his predicament.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Probably not taking caring of myself when I was younger. I didnt get my blood pressure under control until I was
almost 60.
What does your illness mean to you?
I dont know. It is what it is.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Have you ever been sexually active?___Yes. I have two daughters..____________________________
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?____Im not sure.________________________
Have you or your partner received the Gardasil (HPV) vaccination? ___My wife would know.___________________
Are you currently sexually active? ____Yes._______ If yes, are you in a monogamous relationship? Yes.___
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? _____Not much anymore.____________
How long have you been with your current partner?__Sixty three years._____________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ____No.__________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
I dont think so, no.

University of South Florida College of Nursing Revision September 2014

1 SPIRITUALITY ASSESSMENT:
What importance does religion or spirituality have in your life?
____I believe in God and heaven. I think if you good, and you accept Jesus Christ, then there is a place for you in heaven._______
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____It keeps me humble and happy with my life.__________________________________________
______________________________________________________________________________________________________

+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? N/A
How much? N/A

Yes
No
For how many years?
(age

thru

If applicable, when did the

patient quit? N/A

Pack Years: N/A

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

Has the patient ever tried to quit? N/A

If yes, what did they use to try to quit? N/A

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer
How much? 3-5 beers / week
Volume: 36-60 oz / week
Frequency: 3-5 x per week
If applicable, when did the patient quit?
N/A

No
For how many years? Unknown
(age Unknown

thru Unknown

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? N/A
How much? N/A
For how many years? N/A
(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
Not to my knowledge, no.
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

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen None
SPF:
Bathing routine: every other day
Other: bruising worse

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2
x/day
Routine dentist visits
1x/ 2 years
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

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

Genitourinary

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

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 8x/day
Bladder or kidney infections
Patient self-catheterizes due to
Urinary retention

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/15/2016
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever

University of South Florida College of Nursing Revision September 2014

Last EKG screening, when?

Other:

Arthritis
Other:

Chicken Pox
Other:

General Constitution
Recent weight loss or gain
How many lbs? I definitely gained several pounds in the last week or so.
Time frame? In the last week or so.
Intentional? No.
How do you view your overall health? Im trying to be optimistic but I know things arent looking very good.

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?
Im hoping to find somebody who could give us some information about Traditional Chinese Method. Its something me
and me wife have been looking into and wed like to try something a little different.

University of South Florida College of Nursing Revision September 2014

10 PHYSICAL EXAMINATION:
General Survey:
Height 175.26 cm
Weight 75.5 kg
BMI 24.6
Pain: 0
contented talkative, alert Pulse 83
Blood Pressure: 109/68
and oriented x 3
Taken on R.U.E.
Respirations 18
Temperature: 97.7 oral
SpO2 93%
Is the patient on Room Air or O2
Overall Appearance: Hygienic, dressed appropriately
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: awake, anxious, interacts well with others
awake, calm, relaxed, interacts well with others, judgment intact
Speech: Speech was rapid and occasionally anxious.
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Skin was intact but there was generalized bruising over all extremities
Central access device Type:
Fluids infusing?
no
yes

Location:

flat
loud

Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- N/A inches & left ear- N/A inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Moderate gingival recession and tooth decay
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Diminished in all fields
RUL
LUL
RML
LLL
RLL

Chest expansion symmetric

CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent

University of South Florida College of Nursing Revision September 2014

Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Calf pain bilaterally negative

Pulses bilaterally equal 2+
Apical pulse:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
No temporal or carotid bruits
Edema: 2+
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm),
Location of edema: Lower extremities
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

No JVD

DP:
+3 (5-6mm),

PT:
+4(7-8mm) ]

GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date
/
/
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe: UTI present, urine cloudy, foley inserted
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems

Previous 24 hour output: 1550 mLs
without assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus

Strength bilaterally equal at __4___ RUE ___4___ LUE ___4__ RLE

or

with assistance

& ___4__ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

Biceps:

Brachioradial:

Patellar:

Achilles:

Ankle clonus: positive negative Babinski: positive negative

University of South Florida College of Nursing Revision September 2014

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):

Lab
(Normal value: 3.5-5.3)
Potassium: 3.8
Potassium: 3.2
Potassium: 3.5

Dates
2/15/2016
2/16/2016
2/17/2016

(Normal value: < 100)

BNP: 1680
BNP: 1310
BNP: 930
Weight: 77.6 kg
Weight: 76.8 kg
Weight: 75.5 kg

2/15/2016
2/16/2016
2/17/2016
2/15/2016
2/16/2016
2/17/2016

(Normal: 7-20)
BUN: 44
BUN: 55
BUN: 78

2/15/2016
2/16/2016
2/17/2016

(Normal: 0.7-1.3))
Creatinine: 1.7
Creatinine: 1.9
Creatinine: 2.4

2/15/2016
2/16/2016
2/17/2016

(Normal: < 0.01)

Troponin: 0.059
Troponin: 0.065

Trend
Patients potassium levels
have steadily risen since
admission and are
reaching the high end of
normal value range.

Patients BNP levels have

declined but are still far
above normal values.

Analysis
Diuretics used to reduce
the fluid volume
accumulation related to
heart failure often reduce
potassium concentrations.
However, the potassium
supplements provided
have exceeded the
excretory rate and are
now nearing toxic levels.
BNP > 100 indicates an
excess fluid volume

Patients weight has

declined with fluid loss
from diuretics since
admission.

The fluid excretion

induced by the
administration of
diuretics has reduced the
excess fluid volume
related to heart failure
The BUN levels have
The BUN levels are an
been rising since his
indication of renal
admission and are
function and given the
qualified as critical
CKD diagnoses and
values.
administration of
nephrotoxic medications
they continue to rise.
The creatinine levels have The creatinine levels are
been rising since his
an indication of renal
admission and are
function and given the
qualified as critical
CKD diagnoses and
values.
administration of
nephrotoxic medications
they continue to rise.
The troponin levels were
critically high on
admission and continue to
rise.

Troponin levels indicate

2/15/2016
the extent of damage to
2/16/2016
the cardiac tissue. These
values imply that damage
has taken place in the
heart and continues to
take place.
University of South Florida College of Nursing Revision September 2014

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Chest Xray, Diuretics
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Excess fluid volume r/t impaired cardiac functioning leading to decreased renal distribution
AEB: BNP levels of 1680 on 2/15/2016 and 1310 on 2/16/2016
2. Decreased cardiac output r/t congestive heart failure
AEB: ejection fragment of 10-15%
3. Risk for impaired tissue perfusion r/t congestive heart failure
4. Activity intolerance r/t reduced cardiopulmonary capacities
AEB: patient becoming fatigued and short of breath upon minor exertion such as ambulation
5. Impaired urinary elimination r/t benign prostatic hyperplasia and urinary retention
AEB: need for frequent self-catheterizations

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Nursing Diagnosis: Excess fluid volume
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on
Achieve Goal
Provide References
Day Care is Provided
Patient will ambulate fifty feet, three
Assist patient with ambulation
Ambulation helps to mobilize retained fluids Goal met
times by end of shift
and assist with oxygen tank
in heart failure that can accumulate in the
transport
lower extremities if immobile for prolonged
periods (Ackley & Ladwig, 2014).
Patient will continue to progress
Encourage mobility, restrict fluid Mobility will help to mobilize fluids for
Goal met
towards pre-edematous weight by end intake and provide diuretics
excretion. The restricted fluid intake will
of shift
reduce fluid overload and edema, and
diuretics increase fluid excretion to aid in the
progression towards normal body weight
Patient will demonstrate knowledge
Educate patient about the
This education will help to prevent
Goal met
regarding daily weight protocols and
importance of tracking daily
readmission and potential damage to the
dietary restrictions by discharge
weights and dietary restrictions
cardiovascular system because excess fluid
and increased systemic vascular resistance
leads to a greater workload for the heart
Patient will demonstrate knowledge
Educate patient about signs and
This will help to reduce damage by catching Goal met
of the signs and symptoms of fluid
symptoms of fluid overload and
the signs and symptoms of fluid overload
overload and will identify when to
educate patient about when to
early and receiving medical care more
call a health care provider
contact a health care provider
quickly (Ackley & Ladwig, 2014).
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
Ackley B. J.; & Ladwig, G. B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby Elsevier.

University of South Florida College of Nursing Revision September 2014

 15 CARE PLAN
Patient Goals/Outcomes
Patient will have a net fluid output
Of at least 500 mL by end of shift

Nursing Diagnosis: Decreased cardiac output

Nursing Interventions to
Rationale for Interventions
Achieve Goal
Provide References
Encourage safe mobility to
The decreased fluid volume will reduce the
distribute fluids, administer
strain put on the cardiac muscle and will
diuretics
allow for more effective cardiac output

Evaluation of Goal on
Day Care is Provided
Goal met

(Osborn, Wraa, Watson, & Holleran, 2014)

Patient will maintain vital signs

within safe cardiac parameters
(HR<100, BP<130/90)

Administer beta blockers, use

therapeutic communication as
well as environmental
modification to reduce patients
anxiety and stress
Educate patient about the the
signs of decreased cardiac output

Maintaining a therapeutic environment, both Goal met

physically and socially, will reduce the
patients stress and prevent sympathetic,
heart-stimulating response, beta blockers
reduce heart rate and blood pressure
Patient will demonstrate knowledge
This education will help to alert the patient
Goal met
regarding to signs of decreased
about potential signs of decreased cardiac
cardiac output
output so as to detect difficulties early and
begin early and effective interventions
Patient will demonstrate knowledge
Educate patient about dietary
Teaching about the low sodium resitrctions
Goal met
of proper dietary and lifestyle
restrictions as well as functional
(with which the client currently does not
modifications to encourage heart
exercise routines to aid in cardiac comply) will help to diminish retained fluid
health
output safely
volume, thus reducing the work load of the
heart. Also encouraging consistent, safe
exercise routines help to maintain and
improve cardiac functionality (Ackley &
Ladwig, 2014).
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
University of South Florida College of Nursing Revision September 2014

Palliative Care
Ackley B. J.; & Ladwig, G. B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby Elsevier.

University of South Florida College of Nursing Revision September 2014

References

Ackley B. J.; & Ladwig, G. B. (2014). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby Elsevier.
Choose My Plate. (2015, April 3). Nutritional analysis of 24 hour meal consumption.
Retrieved February 19, 2016 from: http://www.choosemyplate.gov/tools-supertracker
Huether, S. E.; & McCance, K.L. (2012). Understanding pathophysiology (5th ed.). St. Louis, MO: Mosby.
Myers, D. G. (2009). Psychology (9th ed.). New York, NY: Worth Publishing Ltd.
Osborn, K.S., Wraa, C.E., Watson, A.B., & Holleran, R. (2014). Medical surgical nursing: Preparation for practice (2 nd
ed). Boston, MA: Pearson Education, Inc.

University of South Florida College of Nursing Revision September 2014

University of South Florida College of Nursing Revision September 2014