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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

Student: Panin Agyen


Assignment Date: 01/22/2015
MSI & MSII Patient Assessment Tool .
Agency: Tampa General Hospital
1 PATIENT INFORMATION
Patient Initials: SW Age: 67 Admission Date: 01/21/2016
Gender: Female Marital Status: Divorced Primary Medical Diagnosis: Atrial Fibrillation
Primary Language: English
Level of Education: BA in Business Management Other Medical Diagnoses: (new on this
admission) Pleural Effusion, Cardiomegaly
Occupation (if retired, what from?): Para-transit driver; retired
Number/ages children/siblings: One daughter-36 y/o;
3 grandchildren; 3 brothers- 56 y/o, 66 y/o, 68 y/o

Served/Veteran: No Code Status: Full Code


Living Arrangements: Patient resides at home with daughter and Advanced Directives: Yes
three grandchildren; patient independently cares for herself and
therefore, does not require assistance with self-care or medications.
There are no stairs in the patients house.
Procedure: 01/21/2015 (CT Angiogram)
Culture/ Ethnicity /Nationality: African American
Religion: Catholic Type of Insurance: Medicare

1 CHIEF COMPLAINT: Patient states, my heart.


3 HISTORY OF PRESENT ILLNESS:
Patient is a 67 year old African-American female with a history of paroxysmal atrial fibrillation, who presented
to the TGH ED with a chief complaint of mid sternal chest pain and shortness of breath; symptoms
spontaneously began three days following her discharge from St. Joseph's, where she had received treatment for
the same manifestations. Upon patient's admission to TGH on 01/21/16, a CT angiogram was performed,
revealing bilateral pleural effusion without evidence of pulmonary embolism. In addition, EKG displayed low
QRS voltage and a deep S wave. At present, patient is continuing to show signs of improvement, including
maintaining normal sinus rhythm and no longer experiencing chest pains or difficulty in breathing due to
administration of pain medications; she currently rates her pain as a 0 out of 10.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date Operation or Illness
04/25/13 Back surgery
Unknown date Tubal litigation
Unknown date Joint replacement
Unknown date Hypothyroidism- Synthroid 50 mcg daily
04/25/13 Low back pain
04/25/13 Indigestion and Gastritis- Protonix 40 mg daily, Pepcid 20 mg daily
Unknown date A-fib- Pacerone 200 mg BID, Eliquis 5 mg BID, Tenormin 25 mg Daily, Toprol-XL 100 mg BID
University of South Florida College of Nursing Revision September 2014 1
Unknown date Elevated transaminases
2015 TEE Cardioversion

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
FAMILY Age (in years)

Heart Trouble
Bleeds Easily

Hypertension
Cause

Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes
Arthritis

Seizures
Anemia

Asthma
HISTORY

Kidney
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 42 Cancer
Mother 87
Brother 56
Brother 66
Brother 68
Paternal
42 Cancer
grandfather
Comments: Patient indicates that her mother, oldest brother, and youngest brother suffer from anxiety. In
addition, arthritis is a common ailment in her family. Patient also indicates that her father died of cancer at the
same age as her paternal grandfather. Patient denies family history of alcoholism, environmental allergies,
anemia, asthma, diabetes, glaucoma, gout, HTN, kidney problems, stomach ulcers, strokes and tumors.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (1970s)
Adult Tetanus (U) Is within 10 years? Yes
Influenza - Patient refuses
Pneumococcal - Patient refuses
Have you had any other vaccines given for international travel or
occupational purposes? Please List

1 ALLERGIES
NAME of
OR ADVERSE Causative Agent
REACTIONS
No known drug
Medications
allergies
No known allergies
Other (food, tape,
to food, tape, latex
latex, dye, etc.)
or dye

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, also known as a-fib, is the most common of all cardiac arrhythmias (Osborn, Wraa,
Watson, & Holleran, 2014); this condition is characterized as irregularly irregular hearts rhythms (Scheinman,
2014) due to failure of the SA node to depolarize the atria. When this occurs, the SA node is unable to transmit
University of South Florida College of Nursing Revision September 2014 2
electrical impulses down to the atria, which interrupts the normal electrical conduction pathway (Osborn et al.,
2014). As a result, the atria begin to quiver rapidly, disrupting ventricular filling (Osborn et al., 2014). Atrial
fibrillation causes irregular ventricular rates, which may reach as high as 200 beats per minute in patients who
are not on medication (Michaud & Stevenson, 2015).
Advancing age is a major predisposing factor in atrial fibrillation; approximately 95% of a-fib patients are
above the age of 60 (Michaud & Stevenson, 2015); therefore, the older one is, the higher the risk of diagnosis.
Other risk factors include diabetes, heart failure, hypertension, coronary artery disease, valvular diseases, and
lung diseases (Scheinman, 2014). In addition, modifiable risk factors such as alcohol use, smoking, caffeine and
stress may increase one's risk for developing a-fib (Osborn et al., 2014).
While some patients with a-fib remain asymptomatic, others may present with chest pain, dyspnea,
palpitations, dizziness, and fatigue (Prystowsky, Padanilam, & Waldo, 2011). The electrocardiogram (ECG) is
an important tool used in the diagnosis of a-fib; an ECG rhythm strip will display very rapid, irregular
ventricular rhythms without the presence of P waves, as well as narrowed QRS complexes (Scheinman, 2014).
Other tools that aid in the diagnosis include echocardiograms and chest x-rays (Scheinman, 2014).
Individuals diagnosed with a-fib are at a greater risk for strokes and embolisms because of the quivering
atria, which prevents adequate outflow of blood from the atria and into the ventricles (Osborn et al., 2014);
Because approximately 25% of all strokes are due to a-fib ((Michaud & Stevenson, 2015), treatment for patients
include anticoagulation therapies. Oral anticoagulant medications such as apixaban are effective against the
prevention of blood clots and embolisms (Michaud & Stevenson, 2015). In addition, warfarin therapy may be
used in patients with a history of strokes or patients with endovascular stents (Michaud & Stevenson, 2015).
Moreover, pharmaceutical classes such as calcium channel blockers and beta blockers are initiated in a-fib
patients in order to decrease and control the ventricular rates (Scheinman, 2014); it is important that the
ventricular rates are managed below 100 beats per minute (Michaud & Stevenson, 2015). Cardioversion may
also be performed in patients within 48 hours of the onset of symptomatic a-fib (Prystowsky et al., 2011). Other
than cardioversion, antiarrhythmic medications such as flecainide and propafenone are long-term therapies for
managing sinus rhythms (Scheinman, 2014).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN
medication. Give trade and generic name.]
Name acetaminophen (Tylenol) Concentration Dosage Amount 650 mg tab

Route PO Frequency Q6 hours PRN


Pharmaceutical class Analgesic/ Antipyretics Home Hospital or Both
Indication PRN mild pain relief
Adverse/ Side effects Nausea, allergic reaction, hepatotoxicity (overdose)
Nursing considerations/ Patient Teaching Instruct patient to not exceed 4 grams over a 24 hour period and to avoid use of alcohol. May be taken with food if GI upset
occurs; monitor for signs/symptoms of toxicity including diarrhea, abdominal pain, diaphoresis and elevated liver enzymes.

Name amiodarone (Pacerone) Concentration Dosage Amount 200 mg tab

Route PO Frequency BID


Pharmaceutical class Antiarrhythmic Home Hospital or Both
Indication Management of cardiac arrhythmias; prevention of atrial fibrillation to maintain normal sinus rhythm
Adverse/ Side effects Dizziness, malaise, increased liver enzymes, hypothyroidism, ataxia/tremors, photosensitivity, worsening arrhythmias
Nursing considerations/ Patient Teaching Monitor BP and pulse before administering. Assess for signs of neurotoxicity such as paresthesia, ataxia or tremors; notify
HCP if bluish discoloration of the face, neck or arms occurs. Instruct patient to take medication as directed and avoid drinking grapefruit juice.

Name apixaban (Eliquis) Concentration Dosage Amount 5 mg tab

Route PO Frequency BID


Pharmaceutical class Factor xa inhibitor Home Hospital or Both
Indication Prevention of blood clots to decrease risk of embolic stroke as a result of atrial fibrillation

University of South Florida College of Nursing Revision September 2014 3


Adverse/ Side effects Nausea, bruising and bleeding, hemorrhage
Nursing considerations/ Patient Teaching Monitor for signs of embolic stroke such as headache; Advise patient to take medication as prescribed and to notify HCP if
easy bruising or bleeding occurs including nose bleeds and gum bleeding. Advise patient to notify HCP of all OTC medications, vitamins or herbal products being used.

Name metoprolol succinate (Toprol-XL) Concentration Dosage Amount 100 mg tab

Route PO Frequency BID


Pharmaceutical class Beta blocker Home Hospital or Both
Indication Management of ventricular rate in atrial fibrillation
Adverse/ Side effects Weakness, fatigue, hypotension, bradycardia, pulmonary edema, heart failure
Nursing considerations/ Patient Teaching Take BP and pulse before administering; do not administer if SBP <100 mmHg or HR<50. Advise patient to swallow tablet
as whole and to change positions slowly. Continue to monitor BP and pulse to assess for hypotension and difficulty breathing.

Name atenolol (Tenormin) Concentration Dosage Amount 25 mg

Route PO Frequency Daily


Pharmaceutical class Beta blocker Home Hospital or Both
Indication Management of ventricular rate in atrial fibrillation
Adverse/ Side effects Weakness, fatigue, hypotension, bradycardia, pulmonary edema, heart failure
Nursing considerations/ Patient Teaching Take pulse before administering; hold if HR <50; Monitor for toxicity with use of other beta blockers; signs include
bradycardia, severe drowsiness and dyspnea. Advise patient to take medication at the same time each day and to change positions slowly; instruct patient on the proper
technique for taking BP and pulse.

Name levothyroxine (Synthroid) Concentration Dosage Amount 50 mcg tab

Route PO Frequency Daily


Pharmaceutical class Thyroid preparation Home Hospital or Both
Indication Thyroid supplementation in hypothyroidism
Adverse/ Side effects Headache, irritability, diaphoresis, heat intolerance, anxiety
Nursing considerations/ Patient Teaching Assess patient for dysthymias and chest pain; assess BP and pulse before administering. Assess patient for arrhythmias and
chest pain. Instruct patient to follow medication regimen each day and to take medication on an empty stomach with a full glass of water, one hour before morning meal.

Name famotidine (Pepcid) Concentration Dosage Amount 20 mg tab

Route PO Frequency Daily


Pharmaceutical class Histamine h2 antagonist Home Hospital or Both
Indication Treatment of gastritis and prophylactic use for stress ulcers
Adverse/ Side effects Confusion, drowsiness, nausea/vomiting, constipation/diarrhea, thrombocytopenia
Nursing considerations/ Patient Teaching Assess for abdominal pain; monitor CBC (platelet count) during administration. Advise patient to change positions slowly
and avoid activities such as driving. Instruct patient to notify HCP of OTC meds such as NSAIDs; notify HCP if rash, confusion or hallucinations occur.

Name pantoprazole (Protonix) Concentration Dosage Amount 40 mg tab

Route PO Frequency Daily


Pharmaceutical class Proton pump inhibitor Home Hospital or Both
Indication Treatment and management of indigestion symptoms
Adverse/ Side effects Headache, flatulence, abdominal pain, pseudomembranous colitis
Nursing considerations/ Patient Teaching Monitor serum magnesium and liver enzymes before and during medication administration; Advise patient to avoid NSAIDs
to minimize GI irritation; Instruct patient to take medication for the required period of therapeutic use.

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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? Heart Healthy Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular diet Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1 serving size of cheerios with whole or soy According to MyPlate, patient consumes a total of
milk; 1 glass of orange juice 1502 calories out of a 2000 caloric diet. Her 24 hour home
Lunch: 1 medium-sized apple and water diet consists of all 5 food groups; she meets the
Dinner: 1 fish fillet (fried or grilled); 1 medium chicken recommended daily intake of fruits through her
breast (fried or grilled); a cup of steamed broccoli or consumption of apples and orange juice. In addition, she
cauliflower receives a majority of her protein intake from dinner; her
Snacks: Trail mix with nuts and fruits (Half a cup) choice of fish and chicken over red meat is important for
Liquids (include alcohol): 6 glasses of water; 1 glass of her overall heart health.
red wine (appr. 5 fl oz.) Moreover, patients consumption of grains is below
the recommended target, with an average of 2.5 oz. a day;
although she receives some percentage of whole grains
through her breakfast, it is not enough to maintain a healthy
cardiovascular and gastrointestinal function. Therefore, it is
recommended that she incorporates more whole grains into
her diet. It is also imperative that patient increases her
intake of vegetables to meet the recommended 2.5 cups
daily; this change will also increase her intake of fiber. Due
to patients age, she is in need of an adequate intake of
dairy; as a postmenopausal woman, she is at risk for
osteoporosis, therefore, it is important that she consumes
about 3 cups of dairy a day in order to maintain strong
bones.
Patients home diet only consists of 1663 mg of
sodium, which is very beneficial for the function of her
heart; continuing to restrict her sodium intake below 2.3
grams will prevent retention of excess body fluids, which
will help to control her blood pressure and cardiac
workload. In addition, her intake of saturated fats is 15
grams, which is within the recommended daily limit.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? Patient indicates that she independently takes care of herself.

How do you generally cope with stress? Patient states, I try to control it.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)Patient
indicates that she has not had any past difficulties with depression or anxiety; in addition, she indicates that she
has not experienced any recent difficulties in her personal and social relationships.

+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? Patient states, No.
Have you ever been talked down to? Patient states, No.
Have you ever been hit punched or slapped? Patient states, No.
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
Patient states, No.
University of South Florida College of Nursing Revision September 2014 5
Are you currently in a safe relationship? Patient states, 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 vs. Despair is the final psychosocial stage of development in Erikson's theory (Treas & Wilkinson,
2014). This stage arises during the late adulthood years, particularly over the age of 65 and continues as one draws near to
their end of life (Treas & Wilkinson, 2014). The goal of this stage is for the individual to find satisfaction regarding their
accomplishments in life; achieving ego integrity allows one to develop acceptance surrounding their inevitable death
(Treas & Wilkinson, 2014). Inability to find a purposeful meaning in one's life results in despair, discontentment with
aging and fear of death (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
At the age of 67 years old, my patient has reached the psychosocial stage of Ego Integrity vs. Despair because she is
now in her late adulthood. During this stage of development, several physical changes occur due to advancing age.
Psychosocially, my patient seems to be developing Ego Integrity over Despair because of her openness, honesty and
strong sense of self-identity. When asked about her present state of wellbeing, she did not hesitate to share her thoughts;
she stated that she was satisfied with her current life, which reveals that she is content with the life she has lived so far and
what she has been able to accomplish.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
This hospitalization has made an impact on my patients developmental stage of life; she has managed to find
positivity through this time, such as when she shared that she is looking forward to getting better and returning home. This
shows that she is aware that her current state of health needs to be improved.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? Patient states, age; it also comes down to genetics.
What does your illness mean to you? Patient states, Its a positive way for me to get better and move on with my life.

+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? Patient states, Of course.

Do you prefer women, men or both genders? Patient states, Men.

Are you aware of ever having a sexually transmitted infection? Patient states, No.

Have you or a partner ever had an abnormal pap smear? Patient states, No.

Have you or your partner received the Gardasil (HPV) vaccination? Patient states, No.

Are you currently sexually active? Patient states, Not right now.

When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? Patient states, Condoms.

How long have you been with your current partner? Patient indicates that she currently doesnt have a partner.

Have any medical or surgical conditions changed your ability to have sexual activity? Patient states, No.

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended
pregnancy? Patient states, No.

University of South Florida College of Nursing Revision September 2014 6


1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life? Patient states, Quite a bit.
Do your religious beliefs influence your current condition? Patient states, No.
______________________________________________________________________________________________________

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


1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
Does anyone in the patients household smoke tobacco? Patient indicates that no one in her household smoke
tobacco.
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? Red Wine How much? 1 glass For how many years?
Volume: 0.6 oz (age 18 thru Present)
Frequency: Weekly
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?
Patient states, No.

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10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Unknown Diverticulitis Life threatening allergic reaction
Bathing routine: Bathes twice a day Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Last colonoscopy? 3-4 yrs. ago
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known: O
Post-nasal drip Normal frequency of urination: 3-5 x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth 2-3 x/day Diabetes Type:
Routine dentist visits As needed/year Hypothyroid
Vision screening Annually Intolerance to hot
Other: Pt wears partial dentures at home Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? 3 yrs. ago Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? 13-14 y.o. Encephalitis
Last CXR? 01/22/16 menopause age? 56 y.o. Meningitis
Other: Date of last Mammogram: N/A Other:
Date of DEXA Bone Density: N/A
Cardiovascular Mental Illness
Hypertension Depression
Hyperlipidemia Schizophrenia
Chest pain / Angina Anxiety
Myocardial Infarction Bipolar
CAD/PVD Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 01/21/16 Arthritis Chicken Pox
Other: Other: Other: Yellow Jaunice in infancy

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General Constitution
Recent weight loss or gain Patient states, No.
How do you view your overall health? Patient states, Its okay; its going to get better.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient states, No.
Any other questions or comments that your patient would like you to know?
Patient states, No.

University of South Florida College of Nursing Revision September 2014 9


10 PHYSICAL EXAMINATION:

General Survey: Height: 165.1 cm/65 Weight: 83 kg BMI: 30.3 Pain: (include rating and
Patient is a 67 y.o. African in location)
American female who is Pulse: 77 beats/min Blood Pressure: 126/72 mmHg Patient reported pain as 0
alert and oriented x4; she Respirations: 23 (Right arm-Brachial artery) out of 10. Prior to
does not display any signs breaths/min hospitalization, she was
of distress. experiencing mid-sternal CP
Temperature: 97.5oF (oral) SpO2 : 97% Is the patient on Room Air or O2: and DIB.
Room Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]


clear, crisp diction

Mood and Affect: pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
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
Central access device Type: Location: Date inserted:
Fluids infusing? no yes - what?
Comments: Tenting occurred upon performing skin turgor; no central or peripheral lines were present; ecchymosis located
on the lateral parts of abdomen as well as inner left forearm.
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 2 mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Comments: Patient reported no pain in the sinus region; however, she indicated that she suffers from occasional sinus
infections. Whisper test was not performed; patient did not have any difficulty with her hearing, as she was responsive to my
questions.
Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
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:
RUL: D LUL: D
RML: D LLL: D
RLL: D
Comments: Lung sounds were auscultated posteriorly and were diminished in the upper and lower lobes d/t bilateral
pleural effusion; patient did not have a cough and was not producing sputum; patient did not report painful or difficult
breathing. However, she did present with chest pain and DIB upon admission.
CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab - Absent
Cardiovascular: No lifts, heaves, or thrills
Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
University of South Florida College of Nursing Revision September 2014 10
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

Comments: ECG strip reveals NSR with a heart rate of 74 beats/min; RR is 23 breaths/min. There is evidence of a P wave
per each QRS, although they do not have a well-defined shape. The PR intervals are present. There are equal spacing
between the QRS complexes; each QRS complex reveals a low voltage due to pleural effusion.

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3 Brachial: 2 Radial: 3 Femoral: N/A Popliteal: 2 DP: 2 PT: N/A
No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Lower extremities-left and right leg pitting non-pitting
Extremities warm with capillary refill less than 3 seconds
Comments: S1 and S2 sounds were present with regular rate. However, rhythm was irregular, in which systolic murmurs
were noted (III/VI).
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 01 / 22 / 16 ) 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: No nausea present.
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
GU Urine output: Clear Cloudy Color: Dark yellow Previous 24 hour output: 600 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness-Not performed

Musculoskeletal: Full ROM intact in all extremities without crepitus


Strength bilaterally equal at 5 RUE 5 LUE 4RLE & 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-N/A
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
Comments: Unable to perform the Rombergs test; patient ambulated to the restroom at a comfortable pace; there was no difficulty in
ambulation; unable to get a reflex hammer to perform DTR.

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

University of South Florida College of Nursing Revision September 2014 11


include why you expect it to be done and what results you expect to see.

Lab Dates Trend Analysis


Potassium Pts admission was 01/21; Potassium is an
2.8 L (01/21) therefore, her trends are electrolyte that is needed
3.8 (01/22) over a period of 48 hours. for muscle contraction
Normal (3.5-5.3) Upon admission, pts K+ and heart function; K+
was below the normal level below a 3.5 is
range. At present, K+ known as hypokalemia,
level is trending at 3.8, which can result from
indicating adequate excess excretion of K+ by
supplementation. the kidneys. However,
excessive use of laxatives
can lead to hypokalemia;
pts use of Miralax can
cause hypokalemia due to
K+ loss through frequent
bowel movements.
Magnesium Upon admission, pts Magnesium plays a role
1.3 L (01/21) Mg+ level was lower than in many cellular and
2.5 (01/22) normal. At present, her muscular functions; these
Normal (1.6-2.6) Mg+ is within the normal lab values measure the
range. concentration of Mg+ in
the blood.
Hypomagnesemia
indicates low Mg+, which
may result from GI or
renal loss. In pts case,
the use of proton pump
inhibitors such as
Protonix can cause
hypomagnesemia.
Protime Pts PT results upon The PT test is to evaluate
17.1 H (01/21) admission were at 17.1, coagulation in those who
17.1 H (01/22) which was above the are on anticoagulants; PT
normal clotting time. measures the time it takes
Normal (9.4-12.5 sec) for ones blood to clot. A
PT above 12.5 secs shows
that blood is clotting at a
slower rate, which
indicates a risk for
bleeding. Due to pts A-
fib, she is on Eliquis to
prevent embolisms; the
use of Eliquis may cause
blood to clot more
slowly. Pts PT elevation
increases her risk for
bleeding.
Platelet Count Upon admission, pts Platelet count measures
University of South Florida College of Nursing Revision September 2014 12
442,000 H (01/21) platelet count was higher the amount of platelets in
388,000 (01/22) than normal. However, ones blood to evaluate
they are now trending the effectiveness of
within the normal range. clotting in preventing
Normal (142,000- bleeding. It is uncertain
424,000mm3 why pts platelet count
was elevated, but it may
be related to the
inflammatory process or
deficiency of vitamins.
Pts platelet count will
need to be monitored
regularly due to a risk for
thrombocytopenia from
the administration of
Pepcid.
Albumin Upon admission, pts Albumin is a protein that
1.8 L (01/21) Albumin level was below is made by the liver; it is
2.5 L (01/22) the normal range. Labs found within the blood
Normal (3.9-4.8) showed a slight increase plasma and it maintains
the following day; oncotic pressure,
however, her albumin allowing for balanced
level is still trending distribution of body
below the normal range. fluids. Low serum
albumin may indicate
inadequate nutrition, GI
disorders, or an
underlining liver/ kidney
problem. Pts
hypoalbuminemia may be
contributing to fluid
retention within the lungs
and edema in the lower
extremities.
CT Angiogram (01/21) Upon admission, a CT Results revealed no
Angiogram was evidence of pulmonary
performed to rule out embolism. However, it
pulmonary embolism and did reveal moderately-
identify the cause for the sized, bilateral pleural
chest pain. effusion that has resulted
in passive atelectasis.
Cardiomegaly with
thickening of the septum
and pulmonary artery of
the heart was also
revealed.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,


multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
University of South Florida College of Nursing Revision September 2014 13
Following admission, patient was placed on a heart healthy diet in order to maintain a low-sodium intake and
prevent excess fluid retention. Patient's sinus rhythms continue to be monitored throughout the shift for
dysrhythmias, which must be communicated to the attending physician. In addition, patient's blood pressure and
heart rate must be taken prior to medication administration in order to ensure that the correct parameters are met;
patient's current treatment consists of home medications such amiodarone, apixaban, atenolol and metoprolol. A
scheduled ECHO was performed on 01/22 to assess the physiology of the heart.

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


1. Altered cardiac output related to impaired ventricular filling due to atrial fibrillation as evidenced by weakened pedal
pulses.

2. Ineffective breathing pattern related to pleural effusion as evidenced by decreased depth of respirations and tachypnea.

3. Impaired gas exchange related to passive atelectasis secondary to pleural effusion as evidenced by diminished lung
sounds, tachypnea, and PaCO2 of 23 mmHg.

4. Impaired nutrition: less than body requirements, related to laxative use and inadequate absorption due to gastritis as
evidenced by decreased serum potassium, magnesium and calcium levels.

5. Altered fluid balance related to hypoalbuminemia as evidenced by fluid accumulation within pleural space and peripheral
edema.

University of South Florida College of Nursing Revision September 2014 14


15 CARE PLAN
Nursing Diagnosis: Altered cardiac output related to impaired ventricular filling due to atrial fibrillation as evidenced by weakened pedal pulses
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will maintain adequate -Assess pt Q4 hours for signs and -The presence of these signs and Goal was met within the specified
cardiac output as evidenced by symptoms of decreased cardiac symptoms indicate heart failure time frame; patients BP and heart
blood pressure within normal range output such as dyspnea, fatigue and (Ludwig & Ackley, pp.198). rate continued to remain within
and heart rate between 60-100 weakness normal limits throughout the shift,
beats/min by the end of shift. -*Administer beta-blockers as -Frequent monitoring will guide demonstrating adequate cardiac
ordered to maintain the ventricular the nurse in understanding when to output. As a result, patients
rate; monitor BP and heart rate hold the medication due to lower cardiac meds were administered as
prior to each administering than normal BP or HR; HCP must scheduled. Patient tolerated
be notified to decide if the activities such ambulating to the
-Provide rest periods from medication needs to be given bathroom without assistance;
activities throughout the day regardless (Ludwig & Ackley, physical exertion was only initiated
pp.198). based on patients tolerance.

-Rest periods help to decrease the


cardiac workload (Ludwig &
Ackley, pp.199).
Patient will continue to maintain -Continuously monitor pts cardiac -amiodarone is an antiarrhythmic Goal was partially met; pt was on
normal sinus rhythm by the end of rhythm on the tele monitoring that is administered in a-fib continuous tele monitoring and no
shift. system patients in order to manage sign of atrial-fibrillation was
-*Administer amiodarone as dysrhythmias picked up by the tele. However,
prescribed patient did continue to experience
some PVCs throughout the shift.
Patient will maintain sufficient -Assess the radial, brachial, and -A diminished or absent pulse is a Goal was partially met; patient
cardiac and peripheral tissue pedal pulses Q2 hours to note for major sign of inadequate perfusion; remained free of chest pains and
perfusion as evidenced by palpable any changes in pulse strength (use it can result in ischemia (Ludwig & her SaO2 continued to measure
pulses and absence of chest pains Doppler if needed) Ackley, pp.641). above 95%, therefore, no
by the end of shift. supplemental oxygen was required.
-Re-assess pts pain Q2 hours - Supplemental oxygen is Pt also remained sitting with HOB
-Put pt on supplemental oxygen of administered in order to improve elevated at high-fowler in order to
2L or as ordered by nasal cannula the O2 saturation and increase facilitate effective breathing and
if pt reports chest pain or SaO2 is perfusion to the heart (Ludwig & circulation.
less 95% Ackley, pp.632).
-Administer IV fluids as ordered
University of South Florida College of Nursing Revision September 2014 15
2 DISCHARGE PLANNING: Patient will maintain adequate urine output of 30 ml per hour or more throughout the rest of hospital stay.
Consider the following needs:
SS Consult
Dietary Consult Refer to dietary to teach client how to maintain a heart healthy diet at home.
PT/ OT- Refer to OT to assist patient in maintaining adequate activity and energy level after discharge.
Pastoral Care
Durable Medical Needs
F/U appointments- Pt will need to follow-up with Cardiologist after discharge.
Med Instruction/Prescription- Educate patient on any changes with home medications and provide instructions for re-fills.
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange related to passive atelectasis secondary to pleural effusion as evidenced by diminished lung sounds, tachypnea, and
PaCO2 of 23 mmHg.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will remain free of -Alternate patients position -Upright positioning improves Goal was met by the end of shift;
respiratory distress by the end of between semi- to high-fowlers oxygenation and ventilation patient did not display any signs of
shift positioning. (Ludwig & Ackley, pp.403). respiratory distress and maintained
oxygen saturation over 95%,
-Place patient on continuous pulse -Oxygen saturation must be indicating proper oxygenation.
oximetry monitoring; obtain order maintained between 95-100%; Patient remained in high-fowlers
for oxygen supplementation for SaO2 <90% indicates significant positioning; lung sounds continued
SaO2 less than 95% oxygenation problems (Ludwig & to be diminished over the lobes,
Ackley, pp.403). however, crackles were not heard.
-Monitor patient every 2 hours for -Altered mentation and behavioral Patient continued to rate pain as a 0
signs of respiratory distress changes are early signs of impaired out of 10.
including restlessness, confusion, gas exchange (Ludwig & Ackley,
agitation and fatigue pp.403).

-Auscultate lung sounds every 2 -Adventitious sounds such as


hours to assess for adventitious crackles or rhonchi indicate airway
sounds obstruction (Ludwig & Ackley,
pp.402) and they require the nurse
-Re-asses pain level and administer to intervene.
University of South Florida College of Nursing Revision September 2014 16
PRN meds as needed
Patient will demonstrate -Position patient in a semi-fowlers
-Upright positioning improves Goal is met when patients
satisfactory respiratory status as to high fowlers position oxygenation and ventilation respirations are maintained at a rate
evidenced by maintaining a (Ludwig & Ackley, pp.403). of 16-20 breaths/min through the
respiratory rate within 16-20 -Monitor respiratory status every 2 -A respiratory rate of 14-16 use of upright positioning, pursed-
breaths/minute, by the end of shift. hours; assess for the rate, depth, breaths/min is considered to be the lip breathing, anxiety reduction,
and breathing effort through the normal range for adults; elevated and periodic rest from activities.
use of accessory muscles. respiratory rate poses a threat to
cardiovascular and respiratory
function (Ludwig & Ackley,
-Encourage the use of pursed-lip pp.402).
breathing and tripod positioning -Evidenced-based clinical research
supports the use of pursed-lip
-Reduce anxiety and fatigue from breathing in improving respiratory
excessive physical exertion function (Ludwig & Ackley,
pp.403).
-Teach patient the importance of -In COPD patients, yearly flu
the flu and pneumococcal vaccines can help to prevent
vaccination; reduce pts risk for exacerbations (Ludwig & Ackley,
infection due to atelectasis and pp.405); patient can benefit from
effusion being vaccinated
2 DISCHARGE PLANNING: Patient will demonstrate improved ventilation as evidenced by audible upper lobe sounds and PaCO2 maintained
within the range of 35-45 mmHg, by the end of discharge.
Consider the following needs:
SS Consult
Dietary Consult- Refer to dietary to teach patient about how to maintain a heart healthy diet at home.
PT/ OT- Refer to OT to assist patient in maintaining adequate activity and energy level after discharge.
Pastoral Care
Durable Medical Needs
F/U appointments- To evaluate ABGs and assess patients respiratory function.
Med Instruction/Prescription- Educate patient on any changes with home medications and provide instructions for re-fills.
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 17


References

Ackley, J.A., & Ladwig B. G. (2013). Nursing diagnosis handbook: An evidenced-based guide to planning

care. St. Louis, MO: Mosby Elsevier.

Michaud G.F., Stevenson W.G. (2015). Supraventricular tachyarrhythmias. In Kasper D, Fauci A, Hauser S,

Longo D, Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine (19th ed.). Retrieved

from http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?bookid=1130&

Sectionid=79742251.

Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Caring for the patient with disorders of the

cardiac conduction system. Medical-surgical nursing: Preparation for practice (pp. 850-868). Upper

Saddle River, NJ: Pearson.

Prystowsky E.N., Padanilam B.J., Waldo A.L. (2011). Atrial fibrillation, atrial flutter, and atrial tachycardia. In

Fuster V, Walsh R.A., Harrington R.A. (Eds), Hurst's The Heart (13th ed.). Retrieved from

http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu/content.aspx?bookid=376&Sectionid=40279

769.

Scheinman M.M. (2014). Atrial fibrillation. In Crawford M.H. (Eds), Current Diagnosis & Treatment:

Cardiology (4th ed.). Retrieved from http://accessmedicine.mhmedical.com.ezproxy.hsc.usf.edu

/content.aspx?bookid=715&Sectionid=48214544.

Treas, S.L., & Wilkinson M.J. (2014). Development: Infancy through middle age. In J. M. Elfrank (Ed.),

Basic Nursing: Concepts, skills & reasoning (pp. 163-164). Philadelphia, PA: F.A. Davis Company.

U.S. Department of Agriculture. ChooseMyPlate.gov. (n.d.). Retrieved from https://www.supertracker.usda

.gov/foodtracker.aspx#data

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University of South Florida College of Nursing Revision September 2014 19