UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
FUNDAMENTAL PATIENT ASSESSMENT TOOL

Student: Krista Caprio

.

Assignment Date: 10/17/14

1 PATIENT INFORMATION
Patient Initials: M,W
Age: 86

Agency: SMH

Gender: Female

Primary Medical Diagnosis: Congestive

Heart Failure
Reason for admission: Shortness of breath

Marital Status: Widowed

Primary Language: English

Level of Education: 10th Grade

Admission Date: 10/16/14

Other Medical Diagnoses: No new medical

diagnoses

Occupation: Retired from working at a grocery store

Number/ages children/siblings: Two sisters: 80,76
One brother: 78, One son: passed away at 68

Served/Veteran: No

Code Status: Full code

Living Arrangements: Lives at home with daughter

Advanced Directives: Yes

Surgery Date: No surgeries
No procedures done

Procedure:

Culture/ Ethnicity /Nationality: Scottish/ Irish

Religion: Protestant

Type of Insurance: Medicare

1 CHIEF COMPLAINT The patient states, My shortness of breath started to get really bad when I went
for lab testing.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital
course of stay) Patient has continuous shortness of breath that is always present, but the other day when she
went for lab testing it got really bad, so the lab tech suggested to her that she should be admitted to the
hospital. The severe shortness of breath caused her to have a heavy feeling on her chest and got worse when she
walked or did any type of activity. Patient did not notice any other symptoms related to the shortness of breath.
Patient has dealt with this issue for a long time and takes medications as well as has a nasal cannula at home.
Patient was admitted to the ER on 10/16/14 for shortness of breath. Electrocardiogram (EKG) was unconfirmed,
also posterior anterior and lateral chest X ray (Chest Pa and lateral) compared to 12/31/12 showed improved
aeration of the lungs with residual pulmonary vascular congestion, no effusion or pneumothorax and no acute
changes in the bones. Patient also received an Echocardiogram (ECHO) showing evidence of regional wall
motion abnormalities, sigmoid hypertrophy of upper interventricular septum, a mild decrease in right
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ventricular systolic function, and the left atrium is mildly dilated. There is mild calcification of the aortic valve,
anterior and posterior mitral leaflet thickening, trace mitral, pulmonic, and tricuspid valve regurgitation. Patient
continues to stay on 2L of a nasal cannula and takes prescribed medications which she normally does at home as
well as isosorbide mononitrate and hydroalazie by mouth (PO) for heart failure.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
Pt does not know
date
1996
1990
1996
1990
1996
1990

Operation or Illness
Arthritis and Osteoporosis: allopurinol 100mg daily
Congestive Heart Failure (CHF): Coreg 6.25mg (twice a day) BID
Hypertension: Norvasc 5mg BID, Coreg 6.25mg BID
Coronary Artery Disease (CAD): Lipitor 10mg nightly at bed time
Hypercholesterolemia: Lipitor 10mg nightly at bed time
Coronary Artery Bypass Grafting (CABG)
Diabetes: Humalog: 0.5-1.2units/kg/day given 15 minutes before a meal and Levemir: 60 units
nightly at bed time
Gastroesophageal Reflux Disease (GERD): Maalox 10ml BID as needed (PRN)

Pt does not know

date
Pt does not know
date

Father
Mother
Brother

38
52
78

Sister
Sister

80

Son

68

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Environmental
Allergies

Cause
of
Death
(if
applicable
)
Kidney
stones
Heart
attack

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Chronic renal failure: Patient does not know treatment for disease

76
Stroke

Comments: Patient does not know age of onset of disease process.

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

YES

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NO

Adult Diphtheria (U)

Adult Tetanus (2006) Is within 10 years?
Influenza (flu) (10/17/14) Is within 1 years?
Pneumococcal (pneumonia) (2012) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
Penicillin

Type of Reaction (describe explicitly)

Patient states, I get this Itching rash, but it is hard to remember
specifically because it was so long ago the first time it happened.

Medications

Patient denies any other allergies

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how
to diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment) Type 2 Diabetes Mellitus is much more common than Type 1 and is more common in Hispanics,
African Americans, and Native Americans. Risk factors include obesity, family history, and female gender. Type
2 Diabetes involves genes that influence either cellular response to insulin, beta cell function, or both. A person
with Type 2 Diabetes is called insulin resistant, this is because there isnt enough insulin being made by the Beta
cells in the pancreas, or the insulin is not binding as it should to its receptors on a cell, thus not allowing glucose
to get into the cells. This will cause a buildup of glucose in the blood and then the body cells are not able to
function properly. Increased glucose in the blood can cause damage to nerves and small blood vessels of the
eyes, kidneys, and heart leading to heart attack or stroke. Type 2 Diabetes can be diagnosed by the following
symptoms: polydipsia, polyuria, polyphagia, weight loss, and hyperglycemia, these symptoms will occur during
times of fasting or after a meal. There is no cure for Type 2 Diabetes, but you are able to manage it. Treatment
consists of bringing the blood glucose levels to normal. This includes dietary restrictions on caloric intake as
well as restrictions on cholesterol and saturated fat levels. If Type 2 Diabetes is related to obesity for an
individual, sometime the loss of weight will improve glucose tolerance. Exercise as well as oral hyperglycemic
agents or insulin therapy is needed to manage blood glucose levels- providing and allowing insulin to bind to its
receptor and letting glucose enter the cell. It is also important to monitor your blood sugar after meals this can
prevent future complications (Huether & McCance, 2008, p. 462-466).
5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.] (Nursing Central from Unbound Medicine)
Name: allopurinol (Zyloprim)

Concentration: 100mg

Dosage Amount: 100mg

Route: By mouth ( PO)

Frequency: Daily
Pharmaceutical class: Xanthine oxidase inhibitors
Home
Hospital
or
Both
Indication: Prevention of attack of gouty arthritis and nephropathy
Adverse/ Side effects: Hypotension, flushing hypertension, bradycardia, drowsiness, diarrhea, nausea, vomiting, renal

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failure, hematuria, rash, uticaria, bone marrow depression, hypersensitivity reactions

Nursing considerations/ Patient Teaching: May cause drowsiness so avoid driving, report skin rash, blood in urine, or
influenza symptoms, alcohol can decrease the effectiveness.
Name: amLODIPine (Norvasc)

Concentration: 5mg

Dosage Amount: 5mg

Route: PO
Frequency: BID
Pharmaceutical class: Calcium channel blockers
Home
Hospital
or
Both
Indication: Alone or with other agents in the management of hypertension, angina pectoris, vasospastic angina
Adverse/ Side effects: Dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival
hyperplasia, nausea, flushing of the skin
Nursing considerations/ Patient Teaching: Take medication as directed even if feeling well, do not double dose, avoid
large amounts of grape fruit juice, contact health care provider if heart rate is <50 beats per minute (bpm), change positons
slowly, avoid driving until response is known, maintain good dental hygiene, use sunscreen and protective clothing, contact
provider if chest pain does not improve or worsens.
Name: asprin (Acetylsalicylic acid)
Route: PO

Concentration: 81mg

Dosage Amount: 81mg

Frequency: Daily

Pharmaceutical class: Salicylates Non- steroidal

Home
Hospital
or
Both
anti-inflammatory drug (NSAID)
Indication: Mild to moderate pain, prophylaxis of Transient ischemic attack (TIA) and Myocardial infarction (MI),
inflammatory disorders such as osteoarthritis
Adverse/ Side effects: Tinnitus, Gastrointestinal (GI) bleeding, nausea, abdominal pain, hepatotoxicity, anemia, hemolysis,
allergic reactions
Nursing considerations/ Patient Teaching: Chew before swallowing, take with a full glass of water, report tinnitus,
unusual bleeding of the gums,, or fever lasting longer than 3 days, avoid use of alcohol, inform health care professional
before surgery, take prescribed dosages.
Name: atorvastatin (Lipitor)

Concentration: 10mg

Dosage Amount: 10mg

Route: PO
Frequency: Nightly at bed time
Pharmaceutical class: Hmg coa reductase inhibitors Home
Hospital
or
Both
Indication: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemia, primary prevention of
coronary heart disease
Adverse/ Side effects: Amnesia, confusion, dizziness, headache, insomnia, memory loss, rhinitis, bronchitis, chest pain,
peripheral edema, abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, pancreatitis, hyperglycemia,
erectile dysfunction, rashes, rhabdomyolysis, hypersensitivity,
Nursing considerations/ Patient Teaching: Take medication as directed, do not double dose, avoid grape fruit juice, this
medication should be used in conjunction with diet restrictions, notify health care provider if any unexplained muscle pain,
tenderness, or weakness occurs.
Name: carVEDilol (Coreg)

Concentration: 6.25mg

Dosage Amount: 6.25mg

Route: PO
Frequency: BID
Pharmaceutical class: Beta Blocker
Home
Hospital
or
Both
Indication: Hypertension, Heart failure (HF), left ventricular dysfunction after myocardial infarction
Adverse/ Side effects: Dizziness, fatigue, weakness, drowsiness, blurred vision, dry eyes, bronchospasms, wheezing,
diarrhea, bradycardia, HF, pulmonary edema, constipation, Steven Johnson syndrome, itching, rashes, toxic epidermal
necrolysis, hyperglycemia, hypoglycemia, anaphylaxis, angioedema, paresthesia
Nursing considerations/ Patient Teaching: Take medication as directed, do not stop abruptly, teach patient how to check
pulse and blood pressure (BP), avoid driving , change positions slowly, patients with diabetes should closely monitor blood
glucose , notify health care provider if slow pulse, difficulty breathing, wheezing, cold hands and feet.
Name: hydrALAZine (Apresoline)

Concentration: 25mg

Dosage Amount: 25mg

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Route: PO
Frequency: BID
Pharmaceutical class: Vasodilators
Home
Hospital
or
Both
Indication: Moderate to severe hypertension
Adverse/ Side effects: Tachycardia, angina, arrhythmias, dizziness, edema, orthostatic hypotension, diarrhea, rash, sodium
retention, peripheral neuropathy, drug induced lupus syndrome
Nursing considerations/ Patient Teaching: Continue take medication even if feeling well, do not double dose, patient
should weigh themselves twice weekly, avoid driving, avoid sudden changes in position, notify health care provider if
general tiredness, fever, muscle or joint aching, chest pain, skin rash occurs.
Name: isosorbide Mononitrte (Isordil)

Concentration: 30mg

Dosage Amount: 30mg

Route: PO
Frequency: Daily
Pharmaceutical class: Nitrates
Home
Hospital
or
Both
Indication: Acute treatments of angina attacks, treatment of chronic heart failure
Adverse/ Side effects: Dizziness, headache, hypotension, tachycardia, paradoxic bradycardia, syncope, nausea, vomiting,
flushing
Nursing considerations/ Patient Teaching: Take medication as directed, even if feeling better, do not discontinue abruptly,
change positions slowly, avoid driving, instruct patient to take last dose of the day no later than 7pm to prevent tolerance,
avoid use of alcohol, notify health care provider if dry mouth or blurred vision occurs.
Name: insulin lispro (Humalog)

Concentration: 100 units/ml in 10

Dosage: 0.5-1.2 units/kg/day
ml vials
Route: Subcutaneous
Frequency: 15 minutes before a meal
Pharmaceutical class: Pancreatics
Home
Hospital
or
Both
Indication: Control of hyperglycemia in patients with type 1 and type 2 diabetes mellitus
Adverse/ Side effects: Hypoglycemia, allergic reactions, lipodystrophy, pruritus, erythema , swelling
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration of insulin, demonstrate
technique for mixing insulin, instruct patient in proper testing of glucose, instruct patient on signs and symptoms of
hypoglycemia and hyperglycemia.
Name: insulin detemir (Levemir)

Concentration: 100 units

Dosage Amount: 60 units

Route: Subcutaneous
Frequency: Nightly before bed
Pharmaceutical class: Pancreatics
Home
Hospital
or
Both
Indication: Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus
Adverse/ Side effects: Hypoglycemia, lipodystrophy, pruitis, erythema, swelling, allergic reactions
Nursing considerations/ Patient Teaching: Instruct patient on proper technique for administration of insulin, demonstrate
technique for mixing insulin, instruct patient in proper testing of glucose, instruct patient on signs and symptoms of
hypoglycemia and hyperglycemia.

Name: polyethylene glycol (Miralax)

Concentration: 260z container

Dosage Amount: 17Gm mixed in

8oz of water

Route: PO
Frequency: Daily
Pharmaceutical class: Osmotics
Home
Hospital
or
Both
Indication: Treatment of occasional constipation
Adverse/ Side effects: Uticaria, abdominal bloating, cramping, flatulence, nausea
Nursing considerations/ Patient Teaching: Inform that 2-4 days may be required to produce a bowel movement ,
excessive use may result in electrolyte imbalance, notify healthcare provider if unusual cramps, bloating, or diarrhea occur.
Name: furosemide (Lasix)

Concentration: 40mg

Dosage Amount: 40mg

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Route: PO
Frequency: BID
Pharmaceutical class: Loop diuretics
Home
Hospital
or
Both
Indication: Edema due to heart failure, hepatic impairment or renal disease, hypertension
Adverse/ Side effects: Blurred vision, dizziness, headache, vertigo, hearing loss, tinnitus, hypotension, anorexia,
constipation, diarrhea, dry mouth, pancreatitis, increased BUN, excessive urination, erythema multiforme, Steven Johnsons
syndrome, hypercholesterolemia, hyperglycemia, dehydration, hypocalcemia, hypokalemia, hyponatremia, metabolic
alkalosis, muscle cramps, fever.
Nursing considerations/ Patient Teaching: Take as directed, do not double dose, use sunscreen and protective clothing,
contact health care provider if rash, muscle weakness, cramps, dizziness, numbness occurs, diabetics should monitor blood
glucose.
Name: magnesium hydroxide (Maalox
Concentration: 5ml
Dosage Amount: 10ml
advanced)
Route: PO
Frequency: BID, PRN
Pharmaceutical class: Antacids
Home
Hospital
or
Both
Indication: GERD
Adverse/ Side effects: Diarrhea, hypermagnesemia
Nursing considerations/ Patient Teaching: Consult health care provider before taking antacids for more than 2 weeks or if
problem is reoccurring, do not take this medications within 2hrs of taking another medication.

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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? Low sodium diabetic diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Low sodium diabetic diet
Consider co-morbidities and cultural considerations):

24 HR average home diet:

Patient indicates she is on a low sodium diet due to her

CHF and a diabetic diet. After comparing to My
Plate overall the patients diet was not too far from
what it should be. She was under the 2,000-calorie diet
at about 1,182 calories. The patient told me her biggest
meal is dinner and she normally doesnt eat much
during the day. The patients cholesterol is over the
recommended amount at about 513mg to the
recommended <300mg this needs to be lowered due to
her heart condition. She may need some patient
education on how to lower this for example, most
cholesterol is found in animal foods, so to reduce
intake choose more plant foods such as fruits and
grains. The patient is also diabetic and on a low sodium
diet this means that her sodium should be at around
1500mg, though she keeps her sodium low at around
1912mg it is not as low as it should be according to
My plate recommendations for people with Diabetes,
this could be due to a lack of complete knowledge
about what foods are low in sodium. The patient can
look for labels that say reduced or low sodium as
well as not seasoning her food with salt. Compared to
all of the food groups the patient did not have any fruit
or dairy in her diet she could fix this by having just a
cup of fruit juice at breakfast instead of coffee or even
a cup of milk, but she must make sure it is fat free or
soy to not increase her saturated fats, because too much
saturated fats is not good for her heart condition.
Because the Patient does not eat much during the day
she must be careful that her diet does not consist of just
empty calories, because calories from liquids are not
nutritionally adequate.

Breakfast: Two frozen waffles- plain fat free, 2 eggs

scrambled with non- stick spray, no milk added
Lunch: High protein liquid 1 cup, 1 peanut bar
Dinner: Medium sized Chicken breast, boneless, skinless,
baked, mixed veggies cooked with vegetable oil 1 cup,
baked potato plain medium sized
Snacks: patient says she does not usually snack
Liquids (include alcohol): 8floz of decaffeinated coffee,
8floz of unsweetened iced tea, usually a cup of water with
dinner

University of South Florida College of Nursing Revision September 2014

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? Usually the patient likes to do things for herself, she cooks and does her own

laundry, but when she is sick or needs something that she is not capable of doing her daughter helps out and
takes care of her.
How do you generally cope with stress? or What do you do when you are upset? The patient tries to relax herself

by doing puzzles like crosswords and word finds, she occasionally watches TV to relax.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life): The

patients son died a month ago from a stroke, this has been difficult for her because it was unexpected, but she
has been going to church every weekend and praying and each day has gotten a little bit better.
+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? _______N/A_________
Are you currently in a safe relationship? Currently not in a relationship with a partner.

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: At age 65 and older we consider our accomplishments throughout life and develop
integrity if we see ourselves as leading a successful life. On the other hand, if we see our lives as
unaccomplished or unproductive we feel guilt about our past not accomplishing our life goals leading to despair.
(McLeod, 2008).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to
your determination: I believe my patient was in the Ego Integrity stage. I thought this, because she is above 65
and when gathering her history and talking to her about her life she seemed very happy and went on into detail
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8

about things she did in her past even when I didnt ask, so you could tell that she really enjoyed sharing her
story. The patient told me how she stopped going to school in 10th grade, but she had to, to be able to help her
family and make money. The first job she had was working at a Soda fountain behind an air force base and loved
working because it kept her active; she later on worked in a grocery store for over 30 years.
Describe what impact of disease/condition or hospitalization has had on your patients developmental
stage of life: My patient stated, I believe my illness is due to family history, everyone had some sort of heart
problem or diabetes, I feel like there wasnt much else I could do to prevent it from happening. Because of this
statement I believe that she was almost expecting this to happen since it is so common in her family. I dont
think her disease had a negative effect on her developmental stage; she does what she is able to do for herself
and is still very independent. My patient was a very pleasant woman to talk to and had a great outlook.
What do you think is the cause of your illness? The patient believes her illness is due to a family history.

What does your illness mean to you? Patient did not know how to answer this question.

+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? _____N/A_______________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? _____Patient does not take any preventative measures_________________________
How long have you been with your current partner?_________30 years but now widowed___________________
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? No

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

What importance does religion or spirituality have in your life?

The patient states, My religion is very important to me. Patient also states, I go to church every
weekend and pray everday.
Do your religious beliefs influence your current condition?
University of South Florida College of Nursing Revision September 2014

____No____________________________________________________________________________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? N/A
How much?(specify daily amount)
N/A

Yes
No
For how many years? X 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?
What? Wine
How much?
Volume: 1 glass
Frequency: with dinner
If applicable, when did the patient quit?
Patient Stopped drinking in 1996

Yes

No
For how many years?
(age 20

thru

68

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
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?

Patient denies using street
drugs

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?

Patient is not a Veteran.

10 REVIEW OF SYSTEMS NARRATIVE (OLDCART THINGS RELATED TO THIS ADMISSION)

General Constitution Patient denies any recent weight loss or gain she tries to maintain a consistent weight
because of her disease (CHF)
How do you view your overall health? Patient states, My health is not so good considering Im in and out of
the hospital all the time.

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10

Integumentary: Patient uses SPF 30 when she goes outside, though she tries to avoid it as much as possible.
Patient bathes one time per day. Patient denies, changes in appearance of skin, problems with nails, dandruff,
psoriasis, hives or rashes, skin infections.
HEENT: Patient brushes teeth two times a day, and goes to the dentist twice a year. Patient goes for vision
screenings once every year. Patient has difficulty seeing and wears glasses. Patient denies Cataracts or
Glaucoma, difficulty hearing, ear infections, sinus pain or infections, nosebleeds, postnasal drip, oral/
pharyngeal infection, and dental problems.
Pulmonary: Patients last chest X ray (CXR) 10/16/14. Patient has difficulty breathing. Patients SOB is
continuous and she doesnt remember when it first started it is aggravated by activity and feels like she cant get
enough air in with a heaviness on her chest and she uses 2L of a nasal cannula at home. Patient denies Cough,
Bronchitis, Asthma, Emphysema, Pneumonia, Tuberculosis, Environmental allergies.
Cardiovascular: Patient has Hypertension, CHF, CAD, patient has been diagnosed with these diseases since the
1990s and takes medication for them. Patients last EKG was on 10/16/14. Patient denies Hyperlipidemia, Chest
pain/ Angina, Myocardial Infarction, Murmur, Thrombus, Rheumatic Fever, Myocarditis, and Arrhythmias.
GI: Patient has GERD and patient does not know when last colonoscopy was. Patient denies Nausea, vomiting,
diarrhea, constipation, Indigestion, Hemorrhoids, Yellow jaundice, Pancreatitis, Colitis, Diverticulitis,
Appendicitis, Abdominal Abscess, Irritable Bowel, Cholecystitis, Gastritis/ Ulcers, Blood in the stool, and
Hepatitis.
GU: Patient has nocturia and polyuria from the Lasix and states, I probably pee about 6 times a day. Patient
denies dysuria, hematuria, kidney stones, and Bladder or kidney infections.
Women Only: Patient denies infection of the female genitalia. Patient states, I do a self-breast exam every now
and then maybe like once a week. Patient does not know when her last gynecological exam was and patient
does not know when her last pap/pelvic exams were. Patient does not know when her last Mammogram was but
she states that it was negative. Patient denies having a DEXA. Patients menstrual cycle was normal, but at age
50 hit menopause.
Musculoskeletal: Patient has Arthritis and weakness in the legs. Patient denies injuries or Fractures, Pain, Gout,
and Osteomyelitis.
Immunologic: Patient denies chills with severe shaking, night sweats, Fever, Human immunodeficiency virus
(HIV), Acquired immunodeficiency syndrome (AIDS), Lupus, Rheumatoid Arthritis, Sarcoidosis, Tumor, Life
threatening allergic reaction, and Enlarged lymph nodes.
Hematologic/Oncologic: Patient does not know blood type. Patient denies Anemia, Bleeding easily, bruising
easily, Cancer, and Blood Transfusions.
Metabolic/Endocrine: Patient has Diabetes Type two and Osteoporosis. Patient denies Hypothyroid/
Hyperthyroidism, and intolerance to hot or cold.
Central Nervous System: Patient denies cerebral vascular accident, Dizziness, Severe Headaches, Migraines,
Seizures, Tricks or Tremors, Encephalitis, and Meningitis.
Mental Illness: Patient denies Depression, Schizophrenia, Anxiety, and Bipolar disorders.
Childhood Diseases: Patient had Measles, Mumps, Chicken Pox, and Whooping Cough. Patient denies Polio,
and Scarlet Fever.

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

No
Any other questions or comments that your patient would like you to know?

NO

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11

10 PHYSICAL EXAMINATION:
General survey: Patient is a pleasant 86 year old who is obese with no visible signs of distress. Patient is alert and
oriented.
Height: 5 9 Weight:__206lbs__ BMI: ___30.4
Pain (include rating and location): ____0__ Pulse:_60 BPM
Blood Pressure (include location):____152/51 right forearm__
Temperature (route taken): _98.5 degrees
Ferinheight orally_
Respirations:_____18__ SpO2: 98%
Room Air or O2: 2L nasal Cannula

Overall Appearance: Clean, hair combed, dresses appropriate for setting and temperature, and maintains eye
contact, no obvious handicaps, besides the walker.
Overall Behavior: Patient is awake, calm, and Relaxed. Patient interacts well with others, judgment intact.
Speech: Clear, crisp dictation.
Mood and Affect: Patient was pleasant, cooperative, and talkative.
Integumentary: Skin is warm, dry, and intact, skin turgor is elastic, no rashes lesions or deformities, nails
without clubbing, capillary refill < 3 seconds, hair evenly distributes, clean, without vermin.
IV Access: Peripheral IV, Type: 22 gauge, located in the left hand, inserted on 10/16/14, no redness, edema, or
discharge, no fluids infusing, no central access device.
HEENT: Facial feature symmetric, no pain in sinus region, no pain or clicking of Temporomandibular Joint
(TMJ), trachea is midline, thyroid not enlarged, no palpable lymph nodes. Sclera is white and conjunctive is clear
without discharge, eyebrow, eyelids, orbital areas, eyelashes, and lacrimal glands are symmetrical without edema
or tenderness, Pupils, equal, round, reactive, to light and accommodation (PERRLA), right and left pupils
symmetric, peripheral vision intact, extra- ocular movements intact through 6 cardinal fields without nystagmus.
Ears symmetric without lesions or discharge, Whisper test heard at equal distance on right and left sides. Nose
without lesions or discharge. Lips, buccal mucosa, floor of mouth, and tongue are pink and moist without lesions.
Teeth were a yellowish discoloration but not missing.
Pulmonary/Thorax: Respirations regular and unlabored, transverse Anterior posterior (AP): 1:1, chest
expansion symmetric, percussion resonant through lung fields and dull towards posterior bases. Sputum
production was thin and in small amounts with a white color. Lung sounds were diminished in all lobes.
Cardiovascular: No lifts, heaves or thrills. S1 S2 audible and regular, no murmurs. Jugular venous distention
(JVD) not appreciated due to body habitus. Calf pain bilaterally negative, Pulses bilaterally equal, Apical pulse:
3, Carotid- not appreciated due to body habitus, brachial: 3, Femoral: not appreciated due to body habitus,
Popliteal: 2 Dorsalis Pedis: 3 Posterior tibial: 3. No temporal or carotid bruits. Edema: 0, non- pitting.
Extremities with capillary refill less than 3 seconds.
GI: Bowel sounds active x 4 quadrants; no bruits auscultated, no organmegaly, percussion dull over liver and
spleen and tympanic over stomach and intestines, abdomen non-tender to palpitation, Last bowel movement
10/16/14 formed , soft, medium brown, genitalia not assessed, patient alert, oriented, denies problem.
GU: Urine output: clear, yellow bathroom privileges with assistance, Costovertebral angle (CVA) punch without
rebound tenderness.
Musculoskeletal: Full range of motion (ROM) intact in all extremities without crepitus, strength bilaterally
equal at 3 in right and left upper extremities and right and left lower extremities (RUE, LUE, LLE, RLE),
vertebral column without kyphosis or scoliosis, neurovascular status intact: peripheral pulses palpable except
femoral and carotid due to body habitus, no pain, pallor, paralysis or paresthesia.
Neurological: Patient awake, alert, oriented to person, place, time and date. Cranial nerve (CN) 1-12 grossly
intact, sensation intact to touch, pain, and vibration, Romberg negative, Sterognosis, graphesthesia and
proprioception intact. Gait smooth, regular with symmetric length of stride while using walker. Deep tendon
reflex (DTR) is 2+ in triceps, Biceps, Brachioradial, Patellar, Achilles, Ankle clonus: positive, Babinski: negative
10 PERTINENT LAB VALUES AND DIAGNOSTC 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
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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
Glucose-

Dates

112 H
97
148 H
235 H
116 H
87
Normal (60-100mg/dl)

Trend
10/16/14
10/16/14
10/16/14
10/16/14
10/17/14
10/17/14

Troponin 1
0.03
0.03
0.02
0.04
Normal (0.00-0.05 ng/ml)

10/16/14
10/16/14
10/16/14
10/17/14

Myoglobin
119 H
113 H
(Normal: 14-106 ng/ml)

10/16/14
10/16/14

Analysis
The patient is Diabetic so
Upon admittance the
it is important to monitor
Patients glucose levels
glucose levels. The
were high, throughout her trending of these high
stay at the hospital the
glucose levels could be
patients glucose levels
due to the amount and
varied but were still in the how often she eats. The
high range.
patient states she does not
eat much throughout the
day and has a bigger meal
at dinner. Consuming
more food in one or two
meals can cause a greater
fluctuation in glucose
levels, but having 3
healthy meals with snacks
in between can help
stabilize blood sugar
levels.
The patients Troponin
levels were in the high
normal range through her
stay at the hospital

The patients myoglobin

levels were high
throughout her stay at the
hospital; it started to
decrease a bit but was
still out of the normal
range.

Troponin protein release

happens when the heart
muscle is damaged such
as in a heart attack.
Having normal troponin
levels after chest pain
means a heart attack is
unlikely. Though the
patients levels were in the
high normal range this
could be due to the fact
that she has been
diagnosed with
Congestive Heart Failure,
so there is some damage
to the heart but not as
much damage that would
occur in a heart attack.
Myoglobin is only found
in the blood stream after
muscle injury. The
patients high levels of
myoglobin could be due
to her previous diagnosis
of CHF since the heart

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muscle has been damaged

and is working much
harder than normal.
BUN
40 H
38 H
(Normal 8-23mg/dl)
Creatinine
1.6 H
1.5 H
(Normal: 0.4-1.1 mg/dl)

10/16/14
10/17/14
10/16/14
10/17/14

Pro- Brian Natriuretic

Peptide
1173
(Normal: age >75 years:
0-1800 pg/ml)

10/16/14

Chest Pa and Lateral

10/16/14

The patients Blood Urea

Nitrogen (BUN) and
Creatinine levels
remained high throughout
her stay in the hospital it
did decrease a little, but
was still out of the normal
range.

Pro-Brain Natriuretic
Peptide was only taken
once during the Patients
stay at the hospital, it was
within the normal range.

Chest X ray was

compared to an X ray
taken from 12/31/12.

The patient has been

diagnosed with renal
failure it is important to
monitor the kidneys.
After the cells use protein
the remaining waste
product Blood Urea
Nitrogen (BUN) is taken
out of the body by the
kidneys, if they kidneys
are not working this
product will stay in the
blood- if the BUN is over
23mg/dl this could be
evidence that the kidneys
may not be working at
full strength. Creatinine is
a waste product from
metabolism of muscles
cells and breakdown of
protein, kidneys excrete
this waste product into
the urine, a Creatinine
over 1.1 mg/dl shows that
the kidneys may not be
working at their full
capacity.
(Huether & McCance,
2008)
Among patients with
dyspnea, NT-proBNP is
highly sensitive for the
detection of acute CHF, a
NT- proBNP < 300 pg/ml
effectively rules out acute
CHF, so though the
patients levels were in the
normal range it was not
less than 300 pg/ml, thus
supporting the CHF
diagnosis. (Lab printout)
Compared to the last
chest X ray there was
improved aeration of the
lungs with residual

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Transthoracic
Echocardiogram

10/16/14

An ECHO was done

during the patients stay at
the hospital.

pulmonary vascular
congestion, no effusion or
pneumothorax without
overt edema. It seems as
though that the patients
medications and lifestyle
are preventing her CHF
from getting worse.
(Lab printout)
This patient has CHF, so
it is important to monitor
the heart to see if any
modifications need to be
made to treatment. The
ECHO showed regional
wall motion
abnormalities, mildly
decreased right
ventricular systolic
function, the left atrium is
mildly dilated, mild
calcification of the aortic
valve, there is mitral,
pulmonic, and tricuspid
valve regurgitation. This
shows that there is
damage to the heart but
with the Patients
medications and
treatment is preventing it
from getting worse.
(Lab printout)

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
This patient is on a low sodium diet to prevent fluid overload. Sodium will hold onto water making more work
for the heart. The hospital also monitors input and output to keep track of how much she is taking in and what the
body is holding onto, because again too much fluid can increase workload for the heart. Daily weights at the
hospital are taken, it is important to monitor weight in CHF, because a sudden change in weight can indicate more
fluid is building up in the body and heart failure is getting worse. Accu checks are taken for this patient to
monitor her blood glucose levels after meals. The patient also had a chest X ray and Echocardiogram done upon
admittance to see if there was any worsening of her condition and to reevaluate treatment.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1.

Excess fluid volume r/t impaired excretion of sodium and water AEB pulmonary congestion

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2.

Activity intolerance r/t weakness and fatigue AEB exertional dyspnea

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 15 CARE PLAN
Nursing Diagnosis: Excess fluid volume r/t impaired excretion of sodium and water AEB pulmonary congestion
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1. Patient will maintain a rating of
1. Monitor location and extent of
1+2: Heart failure is associated
By the end of shift the goal of
0 edema throughout this shift.
edema using the 1+-4+ scale.
with edema because of increased
maintaining a rating of 0 edema
2. Measure the legs using a
water retention in the body; this
was met. The patients leg
millimeter tape; make sure to note
increased water will cause edema
measurements were 750mm on
the differences in each extremity.
in the lower extremities.
both legs and consistent through
3. Monitor input and output.
3. Measuring input and output is
the end of shift. The client had no
important for the client with fluid
trouble voiding or with bowel
volume overload; if the input and
movements, so her inputs and
output is balanced the patient
outputs were similar in amount,
neither gains nor loses water
thus maintaining the rating of 0
weight decreasing the risk of
edema.
accumulation of fluids in the
extremities.
(Ackley & Ladwig, 2010, p.
394,395)
2. Patient will maintain normal
lung sounds (diminished); no
evidence of dyspnea throughout
this shift.

1. Listen to lung sounds for

crackles.
2. Monitor respirations for effort.
3. Patient will use 2L of a nasal
cannula.

1. Pulmonary edema results from

excessive fluid shift from the
vascular space into the pulmonary
interstitial space and alveoli
causing diminished lung sounds.
2. Shifting of fluid into the
interstitial space and alveoli will
result in dyspnea.
3. The nasal cannula will provide
oxygen for the patient to decrease
her difficulty breathing.
(Ackley & Ladwig, 2010, p.
394,395)

By the end of the shift the patients

lung sounds did not change from
the beginning of the day. The lung
sounds were clear though still
diminished which is normal for this
patient. The patient also denied any
difficulty breathing with nasal
cannula that she brought from
home and normally uses.

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3. Patient will maintain weight

gaining no more than 2lbs
throughout this shift.

1. Monitor daily weight for sudden

increases; use same scale and type
of clothing.
2. Monitor intake and output, note
trends reflecting decreasing urine
output in relation to fluid intake.
3. Provide a restricted sodium diet.
4. Implement fluid restriction

1. Body weight changes reflect

changes in body fluid volume.
2. Accurately measuring intake and
output is important for the client
with fluid volume overload if the
input and output is balanced the
patient neither gains nor loses
water weight.
3. Sodium holds onto water, so
restricting sodium from the diet
will decrease the amount of water
held in the body.
4. Fluid restrictions may decrease
intravascular volume and cardiac
workload, thus avoiding weight
gain from excess fluid.
(Ackley & Ladwig, 2010, p.
394,395)

The goal of maintain the same

weight by the end of shift was met.
The patient was 206lbs at the
beginning of the shift and by the
end of shift. The patients input and
output was equal, she had no
trouble voiding though she doesnt
usually eat much during breakfast
and lunch during my shift, but she
was kept on a low sodium diet only
eating lean meat and fresh fruits/
vegetables.

4. **Patient will comprehend and

be able to teach back actions that
are needed to prevent excess fluid
volume including fluid and dietary
restrictions by discharge.

1. Patient education on a low

sodium diet.
2. Patient education on why to limit
fluids.
3. Patient will have a dietary
consult before discharge- patient
will teach back information to me.

1. Restricting sodium in the diet

will favor renal excretion of excess
fluid, and reduce the workload of
the heart since sodium holds onto
water.
2. Fluid restrictions may decrease
intravascular volume and cardiac
workload.
3. A dietary consult will provide
further information on diet before
discharge- giving the opportunity
to teach back will give me the
opportunity to assess if the patient
understands.
(Ackley & Ladwig, 2010, p.
394,395)

Patient goal of comprehending

actions that are needed to prevent
excess fluid volume by discharge
has not been met. The patient has
not been discharged yet nor has she
had a dietary consult or the
opportunity to teach it back to me
so I could assess whether goal was
met.

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2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
X Dietary Consult stated above
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

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References
Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning
care. Maryland Heights, MO: Mosby.
ChooseMyPlate.gov. (n.d.). Retrieved from http://www.choosemyplate.gov/
Huether, S. E., & McCance, K. L. (2008). Understanding pathophysiology. St. Louis, MO: Mosby/Elsevier.
McLeod, S. (2008). Erik Erikson | Psychosocial Stages | Simply Psychology. Retrieved from
http://www.simplypsychology.org/Erik-Erikson.html
Nursing Central from Unbound Medicine

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