UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Rachel Valchine

PATIENT ASSESSMENT TOOL .

Assignment Date: 2/5/14

Agency: Bayfront Medical Center

1 PATIENT INFORMATION
Patient Initials: WG

Age: 65

Admission Date: 2/3/14

Gender: Male

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

I50.22 CHF

Level of Education: Bachelors degree

Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Teacher, currently unemployed

Number/ages children/siblings: No children. One sister (age 60)
who lives in New York.
Served/Veteran: No

Code Status: Full

Living Arrangements: Lives in a 1-story house in St. Petersburg

with wife. No safety considerations to address.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: African American

Religion: Baptist

Type of Insurance: Medicare/Medicaid

1 CHIEF COMPLAINT: chest pain and shortness of breath

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 65-year-old male who presented to the emergency department with complaints of chest pain and pressure that
began at 8:30 AM on day of admission. Patient described the pain as a constant pressure located on the left parasternal
area. The patient reported the chest pain was resolved after nitroglycerin was administered by EMS en route to the
Bayfront ED. The patient reported they had also been experiencing increasing shortness of breath over the past week. An
EKG, 2D echo, and chest x-ray were ordered and showed findings consistent with an acute exacerbation of the patients
CHF. The patient was admitted to 4 South and placed on a tele monitor for further evaluation.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
March 2013
March 2013

Father
Mother

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
)
Stomach
CA

Alcoholism

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness
Acute MI
Angioplasty with stenting x 2

91

Brother
Sister
relationship
relationship
relationship

Comments: Include date of onset

Father: died at age 68 from stomach CA. Patient reports he is unaware of any other health issues his father may have had.
Mother: Mothers history significant for HTN, hyperlipidemia, diabetes, and an MI at age 69. Patient unaware date of onset for
mothers other health issues.

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 (Date) U
Adult Tetanus (Date) U
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

NKA
Medications

NKA
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)
Heart failure is a state in which the heart fails to pump blood at an adequate rate to meet the needs of the tissues it is perfusing
or it is able to do so only with an elevated diastolic blood pressure. Prior to heart failure, the body tries to compensate for the heart by
increasing the preload to help sustain heart function, altering myocyte death and regeneration, and myocardial hypertrophy.
According to Dumitru (2013) norepinephrine is released activating the renin-angiotension aldosterone system (RAAS) and the
sympathetic nervous system. This system acts to maintain arterial pressure and perfusion of vital organs. This activation of the RAAS
leads to salt and water retention by the kidneys which causes an increase in preload of the heart. This increase in preload then leads to
higher energy expenditure of the heart. The primary response to increased stress on the walls of the heart is myocyte hypertrophy,
death, and regeneration. This process subsequently leads to remodeling which only worsens the condition of the heart. This is an area
where many heart failure patients are treated. Medications are frequently used to lower the stress on the heart and slow the remodeling
process. Norepinephrine and epinephrine are also released, causing vasoconstriction and increasing calcium afterload. This causes an
increase in cytostolic calcium entry. The increased calcium entering the cells increases the contractility of the heart and reduces the
hearts ability to relax. The calcium overload can induce arrhythmias and lead to sudden cardiac death while the increase in cardiac
contractility and decrease in the ability to relax increases myocardial energy expenditure. The more energy the heart is using, the more
myocytes die. This causes heart failure and an even larger decrease in cardiac output (Dumitru, 2013).
Approaches to treating heart failure include nonpharmacological, pharmacological and more invasive strategies. If the heart
failure is not severe, nonpharmacological strategies are implemented such as monitoring dietary sodium and fluid intake, increasing
physical activity as appropriate, and paying attention to weight gains. Pharmacological therapies that may be used include the use of
diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, and digoxin. More invasive therapies include pacemakers,
ICDs, and CABG. In extreme cases where other therapies are not effective, a heart transplant may be used (Dumitru, 2013).
According to Heart Failure (2013), some risk factors for an increased preload include incompetent valves, renal failure, volume
overload, and a congentital right to left shunt in the heart. Some risk factors for increased afterload are hypertension, valvular stenosis,
and hypertrophic cardiomyopathy. Risk factors for decreased contractility include cardiomyopathy, coronary artery disease, acute
myocardial infarction, myocarditits, hypocalcelmia, and hypomagnesemia. Any or a combination of these factors can lead to heart
failure. Heart failure has genetic connections as well. It is a complex disorder that combines the actions of many genes with
environmental factors. Many of the risk factors that can lead to heart failure have a genetic predisposition including hypertension,
coronary artery disease, and myocardial infarction (Heart Failure, 2013).
Prognosis for heart failure patients is generally not good. Mortality following hospitalization is 10.4% at 30 days, 22% at 1 year
and 42.3% at 5 years. Each time a patient is rehospitalized, it increases their mortality by about 20%. For the best prognosis, patients
with heart failure should adhere to diet changes, exercise changes, and their medication regimen (Dumitru, 2013).

University of South Florida College of Nursing Revision August 2013

 5 MEDICATIONs: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: Carvedilol

Concentration (mg/ml)

Route: PO

Dosage Amount (mg): 25 mg

Frequency: BID

Pharmaceutical class: beta blocker

Home

Hospital

or

Both

Indication: heart failure

Side effects/Nursing considerations: dizziness, fatigue, weakness, bradycardia, HF, pulmonary edema, SJS, toxic epidermal necrolysis, diarrhea, ED,
hyperglycemia, angioedema. Monitor BP and pulse during dose adjustment period and during therapy, monitor I&Os and daily weight, assess for signs of fluid
overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, JVD).
Name: Digoxin

Concentration

Dosage Amount: 125 mcg

Route: PO

Frequency: Daily

Pharmaceutical class: digitalis glycosides

Home

Hospital

or

Both

Indication: heart failure

Side effects/Nursing considerations: fatigue, arrhythmias, anorexia, n/v. Monitor apical pulse for 1 full min before administration (hold dose if <60 bpm),
monitor ECG throughout administration and 6 hrs after each dose, monitor I&Os.
Name: Furosemide (Lasix)

Concentration:

Route: PO

Dosage Amount: 40 mg
Frequency: daily

Pharmaceutical class: Loop diuretic

Home

Hospital

or

Both

Indication: heart failure

Side effects/Nursing considerations: blurred vision, dizziness, tinnitus, hearing loss, pancreatitis, Stevens-Johnson Syndrome, dehydration, hypocalcemia,
hypokalemia, metabolic alkalosis, aplastic anemia, agranulocytosis; monitor daily weight and I&Os; monitor blood pressure and pulse before and during
administration; assess patient for tinnitus and hearing loss; assess patient for skin rash frequently; monitor potassium levels and renal fuction before
administration.
Name: Lisinopril (Zestril)

Concentration

Dosage Amount: 20 mg

Route: PO

Frequency: BID

Pharmaceutical class: ACE inhibitor

Home

Hospital

or

Both

Indication: hypertension, heart failure

Side effects/Nursing considerations: dizziness, fatigue, HA, cough, hypotension, angioedema. Monitor BP and pulse frequently during dosage adjustment and
during therapy, assess pt for signs of angioedema (dyspnea, facial swelling), monitor weight and assess for fluid overload, monitor renal function and potassium
levels.
Name: Nicotine (Nicoderm C-Q)

Concentration

Dosage Amount: 14 mg

Route: transdermal

Frequency: daily

Pharmaceutical class

Home

Hospital

or

Both

Indication: smoking cessation

Side effects/Nursing considerations: HA, insomnia, tachycardia, burning at patch site, erythema, pruritis. Assess smoking history prior to therapy, assess patient
for symptoms of smoking withdrawal, monitor for signs of toxicity.
Name: Spironolactone (Aldactone)

Concentration

Dosage Amount: 25 mg

Route: PO

Frequency: daily

Pharmaceutical class: potassium-sparing diuretic

Home

Hospital

or

Both

Indication: management of edema associated with HF

Side effects/Nursing considerations: hyperkalemia, dizziness, SJS, agraulocytosis, arrhythmias. Monitor I&Os, assess for development of hyperkalemia, assess
for skin rash, monitor electrolyte levels.
Name: Morphine (MS Contin)

Concentration: 1 mg/0.25 mL

Route: IV Push

Dosage Amount: 1 mg

Frequency: PRN Q1H

Pharmaceutical class: opioid agonists

Home

Hospital

or

Both

Indication: severe pain

Side effects/Nursing considerations: confusion, sedation, respiratory depression, hypotension, constipation, euphoria. Assess LOC, BP, pulse, and respirations,
before and periodically during administration. Assess bowel function routinely.

University of South Florida College of Nursing Revision August 2013

Name: Nitroglycerin (Nitrostat)

Concentration

Dosage Amount: 0.4 mg

Route: SL

Frequency: PRN

Pharmaceutical class: nitrates

Home

Hospital

or

Both

Indication: acute management of angina pectoris

Side effects/Nursing considerations: dizziness, HA, hypotension, tachycardia, blurred vision, abdominal pain, N/V. Assess location, duration, intensity, and
precipitating factors of patients angina pain, monitor BP and pulse before and after administration.
Name: Ondansetron (Zofran)

Concentration: 2 mg/ml

Route: IV Push

Dosage Amount: 4.0 mg

Frequency: PRN Q4H

Pharmaceutical class:5-HT3 antagonists

Home

Hospital

or

Both

Indication: Prevention of nausea/vomiting

Side effects/Nursing considerations: headache, torsades de pointes, constipation, diarrhea. Assess pt for n/v, abdominal distention, and bowel sounds prior to and
following administration. Assess pt for extrapyramidal effects.

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients intake of grains, vegetables, fruits, and dairy
is considerably less than the recommended daily amount.
Breakfast: 1 cup Cheerios cereal with 4 oz skim milk
Of particular concern for this patient is the excessive
amount of sodium present in his diet as this can cause fluid
Lunch: 2 pieces white bread, 4 Tbs peanut butter, 1 medium retention that can exacerbate CHF. Heart failure patients
banana, 1 small bag potato chips
are typically recommended to consume no more than 2,000
mg per day. The patients typical consumption was more
Dinner: 1 cup rice and beans, 1 chicken breast
than 2,300 mg. I would recommend that this patient avoid
packaged foods, replace salty snacks with fresh fruits and
Snacks: 1 cup buttered popcorn
vegetables, and consider using salt-free herb blends when
cooking to add flavor without the extra sodium.
Liquids (include alcohol): 16 fl oz coffee, 24 fl oz beer, 16
oz Coca Cola

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife.
How do you generally cope with stress? or What do you do when you are upset?
Talking with my wife or family helps a lot
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reports no recent feelings of depression/anxiety.

+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?

University of South Florida College of Nursing Revision August 2013

Are you currently in a safe relationship? Yes.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
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: According to McLeod (2008), generativity vs. stagnation occurs in middle adulthood. The objective of this stage
is to begin to establish careers, family, and become involved in the community. If these objectives are not achieved the result is
stagnation or a feeling of being unproductive (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 is in the self absorption/stagnation stage. The patient stated they have been having difficulty staying
active within his church community (something that he used to do regularly), is currently unemployed, and has been
actively using illicit drugs. This suggests his development is somewhat stagnant at the moment.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I think my patients disease process has had a profound impact on their development. It is possible that his drug usage and
unemployment could be related to the stress of his disease.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My body just isnt what it used to be. Ive been dealing with this for a long time.
What does your illness mean to you?
It seems to be a never-ending challenge.

+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? Women.
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? Yes. When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? None.
How long have you been with your current partner? 33 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?
No.

University of South Florida College of Nursing Revision August 2013

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

What importance does religion or spirituality have in your life?
I am a man of faith. I try to stay active within my church but its been hard lately. My wife keeps trying to make me go with her but I
havent been in quite some time.
Do your religious beliefs influence your current condition?
I have to put faith in God that he will take care of me.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
Yes
No
If so, what? cigarettes
How much?(specify daily amount)
For how many years? 48 years
One pack every other day (approx. 10
(age 17 thru 65)
cigarettes per day).
If applicable, when did the
patient quit?

Pack Years: 24
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? No

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? beer
How much? (give specific volume)
2 beers/day (24 fl oz)

For how many years?

(age 17 thru 65)

If applicable, when did the patient quit?

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? Cocaine. Patient initially denied cocaine usage until lab tests came back positive for the substance. Patient
was guarded on the subject and refused to talk about usage but did state he had used as recently as 2/2/14.
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No
Most recent use 2/2/14

thru

If not, when did he/she quit?

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

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: daily
Other:

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
Routine dentist visits
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? U
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:
Bladder or kidney infections

7x /day

Hematologic/Oncologic

Metabolic/Endocrine
x/day
x/year

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? 2/3/14
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 2/3/14
Other:

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? annually
Date of last prostate exam? 07/13
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
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)
Pts perception of health: Im not doing so great.

Integumentary:
HEENT:
Pulmonary: Patient admitted with difficulty breathing but has since resolved. Patient is currently on 2L nasal
cannula and was able to ambulate on the floor without significant drop in O2 saturation. Last CXR on 2/3/14
showing cardiomegaly with pulmonary vascular congestion.
Cardiovascular: Patient diagnosed with hyperlipidemia and hypertension currently well controlled with
medication. Last EKG on 2/3/14 showing a normal sinus rhythm with no acute changes. Patients recent
admission is likely due to an exacerbation of his CHF.
GI:
GU:
Women/Men Only: Patient reports he has an annual prostate exam, the last one was in July of 2013 with no
abnormal findings.
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:

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.

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is
Height: 70 inches
Weight:167.4 BMI: 24
Pain: (include rating & location)
alert and oriented times 3, in Pulse: 83
Blood
4/10 (head)
no acute distress, appears
Pressure: 110/65 (LFA)
(include location)
stated age
Temperature: (route taken?)
Respirations: 16
98.5 (oral)
SpO2: 92%
Is the patient on Room Air or O2: nasal cannula 2L
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
apathetic
bizarre
agitated
anxious
tearful
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

Peripheral IV site Type: 20 G

no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Peripheral IV site Type: 20 G
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

talkative
withdrawn

quiet
boisterous
aggressive
hostile

Location: LH

Date inserted: 2/5/14

Location: RFA

Date inserted: 2/4/14

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 4 / 4 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: overall good dentition, no missing or damaged teeth.
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
CR - Crackles
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

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 lobes.

Cardiovascular:
No lifts, heaves, or thrills PMI felt at: midclavicular 5 th ICS
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 2+ Carotid: 2+ Brachial: 2+ Radial: 2+
Femoral: 2+ Popliteal: 2+
DP: 2+
PT: 2+
No temporal or carotid bruits
Edema: 0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
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
Urine output:
Clear
Cloudy
Color: straw yellow
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 2 / 4 /14)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at 5 RUE 5 LUE 5 RLE

&

5 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 parathesias

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: 2+

Biceps: 2+

Brachioradial: 2+

Patellar: 2+

Achilles: 2+

Ankle clonus: positive negative Babinski: positive negative

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
BNP
1,736 pg/mL (HIGH)
1,069 pg/mL (HIGH)

Dates
2/3/14
2/4/14

CK MB
9.0 (CRITICAL)
11.6 (CRITICAL)
8.6 (CRITICAL)

2/3/14, 10:50
2/3/14, 16:42
2/3/14, 23:30

Troponin
0.03 g/L
0.04 g/L
0.04 g/L

2/3/14, 10:50
2/3/14, 16:42
2/3/14, 23:30

Trend
Upon admit, the patients
BNP was elevated to
1,736. The next draw on
2/4/14 showed a reduced
level at 1,069.
Patients labs showed an
increase and then
decrease in CKMB levels
while within the hospital
setting.

Patients troponin levels

were only slightly
elevated to 0.03 g/L
when first drawn.
Subsequent draws both
yielded results of 0.04
g/L.

Echocardiogram

2/3/14

Ejection fraction of 30%.

No other
echocardiograms were
performed for
comparison.

Drug Screen

2/3/14

Positive for cocaine

Analysis
BNP levels above 900
pg/mL indicative of
severe heart failure.
CKMB levels indicated
damage to myocardial
muscle. They can be
detected within 3 to 8
hours of the onset of chest
pain, peak within 12 to 24
hours, and usually return
to baseline levels within
24 to 48 hours.
The presence of low
troponin levels indicates
there was previous
damage to the heart
muscle. The low levels
and stability of these
levels over time suggests
the patient is likely not
currently experiencing an
MI.
Depressed left ventricular
function indicating
weakening of the heart
muscle. Indicative of
dilated ischemic
cardiomyopathy.
Cocaine usage is

EKG

2/3/14

Non-specific ST changes.
No evidence of acute
change. No other EKGs
were performed for
comparison.

CXR

2/3/14

CXR showed
cardiomegaly with
pulmonary vascular
congestion.

commonly associated
with many heart problems
such as heart failure, heart
attack, and dilated
cardiomyopathy.
Patients PMH is
significant for an acute
MI in March of 2013.
EKG results are likely a
result of this past cardiac
event.
Enlargement of the heart
does not allow blood to
pump effectively,
resulting in heart failure.

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

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently on a cardiac diet with vitals scheduled Q4H. He is currently on 2L nasal cannula and can
ambulate with assistance. The patient will continue to consult with cardiology on the possibility of biventricular
pacing.

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

1. Decreased cardiac output r/t impaired cardiac function
2. Impaired gas exchange r/t excessive fluid in interstitial space of lungs
3. Excess fluid volume r/t impaired excretion of sodium and water
4. Activity intolerance r/t imbalance O2 supply and demand aeb weakness, fatigue
5. Risk for ineffective tissue perfusion r/t decreased cardiac output
6. Risk for ineffective breathing pattern r/t pulmonary congestion secondary to CHF

 15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t altered contractility aeb decreased ejection fraction
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
1. Sinus tachycardia and increased arterial
blood pressure are seen in the early stages;
BP drops as the condition deteriorates.
2. Cold, clammy skin is secondary to
compensatory increase in sympathetic
nervous system stimulation and low
cardiac output and desaturation.
3. Pulses are weak with reduced cardiac
output
4. Compromised regulatory mechanisms
may result in fluid and sodium retention.
Body weight is a more sensitive indicator
of fluid or sodium retention than intake
and output.
5. Crackles reflect accumulation of fluid
Patient will remain free of side effects
secondary to impaired left ventricular
from the medications used to achieve
emptying. They are more evident in the
adequate cardiac output through hospital
dependent areas of the lung.
discharge.
6. Physical activity increases the demands
placed on the heart; fatigue and exertional
dyspnea are common problems with low
cardiac output states. Close monitoring of
patient's response serves as a guide for
optimal progression of activity.
7. Indicates an imbalance between oxygen
supply and demand.
8. Adherence to medication regimen helps
to control symptoms, keep vitals within
normal limits, and prevent further
exacerbation of CHF.
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
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Patient will demonstrate adequate cardiac
output aeb blood pressure, pulse rate and
rhythm within normal parameters for the
client.

1. Assess HR and BP
2. Assess skin color and temperature
3. Assess peripheral pulses
4. Assess fluid balance and weight gain.
5. Assess lung sounds.
6. Assess response to increased activity
7. Assess for chest pain
8. Administer medication as prescribed,
noting response and watching for side
effects and toxicity. Clarify with physician
parameters for withholding medications.

1. Patient maintained HR and BP within

normal limits.
2. Patients skin was normal for ethnicity
and dry. Patients skin was warm upon
assessment.
3. Patients peripheral pulses present on
assessment.
4. No weight gain or loss reported on my
shift.
5. Lung sounds were clear but diminished
in all lobes.
6. Patient able to ambulate with assistance
in hallway without significant decrease in
O2 saturation.
7. Patient did not report any chest pain
during my shift.
8. All medications administered to patient
as ordered.

Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange r/t excessive fluid in interstitial space of lungs
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
1. A study by Hagle (2008) demonstrated
1. Patient maintained normal respiratory
Patient will demonstrate improved 1. Monitor respiratory rate, depth, and
ease of respiration. Watch for use of
that when the respiratory rate exceeds 30
rate and ease of respiration.
ventilation and adequate
accessory muscles and nasal flaring.
breaths/min, along with other
2. Bread sounds were clear but diminished
oxygenation.
2. Auscultate breath sounds every 1 to 2
physiological measures, a significant
in all lobes. No adventitiuous breath
Patient Goals/Outcomes

hours. Listen for diminished breath

sounds, crackles, and wheezes.
3. Monitor the clients behavior and
mental status for the onset of restlessness,
agitation, confusion, and (in the late
stages) extreme lethargy.
4. Monitor O2 saturation continuously
using pulse oximetry.
5. Observe for cyanosis of the skin;
especially note color of the tongue and
oral mucous membranes.
6. Position the client in a semirecumbent
position with the HOB at 30- to 45-degree.
7. Administer humidified oxygen through
an appropriate device; aim for an O2
saturation level of 90% or above.

cardiovascular or respiratory alteration

exists.
2. The presence of crackles upon
auscultation may alert the nurse that the
patient is experiencing fluid overload.
3. Changes in behavior and mental status
Patient will maintain clear lung
can be early signs of impaired gas
fields and remain free of signs of
exchange.
4. Pulse oximetry is useful for tracking
respiratory distress.
and/or adjusting supplemental oxygen
therapy for clients.
5. Central cyanosis of the tongue and oral
mucosa is indicative of serious hypoxia
and is a medical emergency.
6. An upright position allows for maximal
lung expansion; lying flat causes
abdominal organs to shift toward the
chest, which crowds the lungs and makes
it more difficult to breathe.
7. Supplemental O2 should be titrated to
improve the clients hypoxemia with a
target of 88% to 92% O2 sat
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 appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

sounds were heard.

3. Patient was calm and pleasant during
my shift.
4. Patient maintained adequate O2
saturation, even while ambulating.
5. No central or peripheral cyanosis noted
upon assessment of the patient.
6. Patients HOB was maintained in a 30to 45-degree angle during my shift.
7. Supplemental O2 used consistently
throughout my shift. The patient
maintained an adequate O2 saturation.

References
Ackley, B. & Ladwig, G. (2014). Nursing diagnosis handbook : an evidence-based guide to planning care. Maryland Heights, Missouri: Mosby
Elsevier.

Dumitru, I. (2013, October 1). Heart Failure-Pathophysiology. Retrieved from Medscape: http://emedicine.medscape.com/article/163062overview#aw2aab6b2b3

Heart Failure. (2013, October 8). Retrieved from Nursing Central : http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-andDisorders/73601/all/Heart_Failure

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis: Elsevier.

McLeod, S. A. (2008). Erik Erikson | Psychosocial Stages - Simply Psychology. Retrieved from:
http://www.simplypsychology.org/Erik-Erikson.html