UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Kacy McMurry

MSI & MSII PATIENT ASSESSMENT TOOL .

Agency: TGH

1 PATIENT INFORMATION
Patient Initials:
Gender:

R.T.

Male

Assignment Date: 2/6/2015

Age: 47

Admission Date: 2/4/2015

Marital Status: Married

Primary Medical Diagnosis:

Primary Language: English

Level of Education: High School

Volume excess (276.69) due to left sided heart

failure
Other Medical Diagnoses: (new on this admission)

Occupation (if retired, what from?): Unemployed

Ischemic Cardiomyopathy

Number/ages children/siblings: No children or siblings

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

Code Status: Prior-VAD patient

Living Arrangements: Lives with wife and uncle

Advanced Directives: Yes

If no, do they want to fill them out?
Surgery Date: 2/6/2015
Procedure:

Culture/ Ethnicity /Nationality: Caucasian

Thoracentesis

Religion: Methodist

Type of Insurance: Medicaid

1 CHIEF COMPLAINT: Pt. came into ER complaining that he had gained 10 pounds in one week.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Pt. had a history of left sided heart failure, so a LVAD Heartmate II was placed 10/30/2013. He was seen in a clinic for
weight gain and volume excess on 2/6. He reported leg swelling and abdominal fluid that was associated with shortness of
breath that began over the weekend. His brain natriuretic peptide was elevated with a level of 124. He was recently
Hospitalized for the same issue 12/30/14-1/12/15. Important to note is that he has had various different admissions
For narcotic dependence and noncompliance. Pt. is supposed to use Bipap machine at all times, but he is not complying so
he continues to desat into the low 70s. Patient had a thoracentesis on 2/6/15 where 1,000mL of fluid were removed.
Pt. was put on a continuous Lasix drip to decrease fluid retention. Due to low compliance with treatment options,
palliative care is being consulted.

University of South Florida College of Nursing Revision September 2014

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
8/30/2013
10/30/2013
5/3/2014
10/12/2014
11/16/2014
12/30/14

Father

72

Mother

75

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
)
Heart
attack
Natural
death

Alcoholism

Acute Kidney Injury

VAD inserted
CAD-Coronary Artery Disease
Anemia
Opiate overdose
Congestive Heart Failure

Age (in years)

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Brother
Sister
relationship
relationship

Comments: Father had a heart attack at 72 and died from a heart attack. Pt.s mother died from natural causes.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (
Adult Tetanus (Date) Is within 10 years? Yes U
Influenza (flu) (Date) 12/17/15
Pneumococcal (pneumonia) (Date) Is within 5 years? U
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

University of South Florida College of Nursing Revision September 2014

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No Known Allergies

Medications

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)
Left sided heart failure is also known as congestive heart failure, which is basically an inability of the heart to generate
An appropriate cardiac output to perfuse vital organs and tissues. The cardiac output is based on the heart rate and stroke
Volume. Several different things can cause the stroke volume to drop, causing the heart failure. Clinical manifestations
Of left sided heart failure are the result of pulmonary vascular congestion that do not provide appropriate systemic
Circulation. Symptoms include froth sputum, fatigue, decreased urine output, edema, fluid retention, hypo or hypertension
, and often times crackles or pleural effusions. Management of left sided heart failure involves reducing preload and
Afterload. Salt restrictions and diuretics are helpful with reducing the preload. ACE inhibitors help with both preload
And afterload. Cardiac resynchronization therapy is becoming more popular and showing effective. Surgery may be
Necessary for treatment. Death occurs frequently with these patients. Risk factors for left sided heart failure include
Hypertension, coronary artery disease, faulty heart valves, cardiomyopathy, and heart arrhythmias (Heuther, 2008).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name ducosate sodium (Colace)

Concentration

Dosage Amount 100 mg

Route oral

Frequency 2 times daily

Pharmaceutical class stool softeners

Home

Hospital

or

Both

Indication Prevention of constipation

Adverse/ Side effects throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching assess daily bowel movements to see if Colace is still needed
Name DULoxetine (Cymbalta)

Concentration

Dosage Amount 60mg

Route Oral

Frequency daily

Pharmaceutical class selective serotonin and norepi. Reuptake inhibitor

Home

Hospital

or

Both

Indication Major depressive disorder

Adverse/ Side effects seizures, suicidal thoughts, drowsiness, insomnia, constipation, dysuria
Nursing considerations/ Patient Teaching assess for suicidal ideation
Name aspirin EC tablet

Concentration

Dosage Amount 325 mg

Route oral

Frequency daily

Pharmaceutical class salicylates

Home

Hospital

or

Both

University of South Florida College of Nursing Revision September 2014

Indication blood thinner

Adverse/ Side effects GI bleeding, dyspepsia, nausea, anemia, abdominal pain
Nursing considerations/ Patient Teaching assess for GI bleeds, give with food to prevent stomach irritation
Name finasteride (PROSCAR)

Concentration

Dosage Amount 5 mg

Route oral

Frequency daily

Pharmaceutical class androgen inhibitors

Home

Hospital

or

Both

Indication Benign prostatic hyperplasia

Adverse/ Side effects gyneocomastia, prostate cancer, breast cancer
Nursing considerations/ Patient Teaching assess urine symptoms
Name insulin aspart (NovoLog)

Concentration

Dosage Amount 4-16 units

Route subcutaneous

Frequency 3 times daily with food and at bedtime

Pharmaceutical class pancreatics

Home

Hospital

or

Both

Indication control of diabetes mellitus type 2

Adverse/ Side effects hypoglycemia, erythema, swelling, anaphylaxis
Nursing considerations/ Patient Teaching monitor blood sugar levels, assess when patient will be eating meals
Name insulin glargine

Concentration

Dosage Amount 10 mg

Route subcutaneous

Frequency nightly

Pharmaceutical class pancreatics

Home

Hospital

or

Both

Indication control of diabetes mellitus type 2

Adverse/ Side effects hypoglycemia
Nursing considerations/ Patient Teaching assess patients blood sugar levels, long term insulin
Name meTOPROLOL succinate (TOPROL-XL)

Concentration

Dosage Amount 50 mg

Route oral

Frequency daily

Pharmaceutical class beta blocker

Home

Hospital

or

Both

Indication hypertension
Adverse/ Side effects fatigue, bradycardia, heart failure, depression,
Nursing considerations/ Patient Teaching monitor BP, ECG, and pulse frequently
Name potassium chloride SA

Concentration

Dosage Amount 40 mEq

Route oral

Frequency 2 times daily

Pharmaceutical class mineral and electrolyte replacement/supplement

Home

Hospital

or

Both

Indication Treatment of potassium depletion

Adverse/ Side effects confusion, abdominal pain, ECG changes, diarrhea, flatulence
Nursing considerations/ Patient Teaching assess for signs of hypokalemia, watch ECG, take with food or a full glass of water
Name furosemide (Laxix) in sodium chloride

Concentration 3mg/mL

Route intravenous

Dosage Amount 100 mL

Frequency continuous

Pharmaceutical class loop diuretics

Home

Hospital

or

Both

Indication edema due to heart failure

Adverse/ Side effects dehydration, hypokalemia, hypocalcemia, metabolic acidosis, muscle cramps
Nursing considerations/ Patient Teaching monitor I&O, monitor BP and pulse before administration

University of South Florida College of Nursing Revision September 2014

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? No specific diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient not only has coronary artery disease along with
Breakfast: 4 pieces of bacon, 2 waffles with syrup
heart failure, but he also has diabetes mellitus type 2, so he
needs to be extra careful with what he eats. He needs to
Lunch: BLT sandwich on white bread with potato chips
watch his blood sugar levels as well as limit his intake of
fatty foods. Patient needs to include fruits and vegetables
Dinner: Fried chicken leg with mashed potatoes and green
into his diet. For example, instead of eating bacon and
Beans
waffles with super sugary syrup on it, he could eat a fruit
Snacks: sour candy, chips, chocolate ice cream
cup with oatmeal, a healthy substitution. His blood sugar
levels are consistently high, and his diet is not helping.
Liquids (include alcohol): water, 2 cans of coke, orange
Juice
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? My wife and uncle take care of me and my VAD.
How do you generally cope with stress? or What do you do when you are upset?
I like to watch tv and eat food when I feel stressed. I try to avoid my family when Im upset, they usually cause the
stress.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Ive felt depressed lately, but that happens a lot.

+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? _No__________________
Are you currently in a safe relationship? Yes

University of South Florida College of Nursing Revision September 2014

 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

During middle adulthood, careers and relationships become established, they can give back to the community through raising their

children, work, and being active in the community. By failing these tasks we become stagnant. With success, these tasks
will lead to virtue of care.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

My patient is in the stagnation stage of development. He isnt being productive in society. He doesnt work, he isnt
raising children, nor does he have any. He sits at home and does not contribute to society. My patient does not seem to be
giving back, rather he seems to be not moving forward in life.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

I feel as if having the VAD and heart failure have made this patient feel like he cannot be productive in his life, so he
just gave up with trying to give back.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Life just isnt fair.
What does your illness mean to you?
I probably did something in life at some point, where Im being punished now.

+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_________________ If yes, are you in a monogamous relationship?
______Yes__________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _None_________________________
How long have you been with your current partner?____27 years____________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _My VAD___________________
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 September 2014

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

What importance does religion or spirituality have in your life?
_It doesnt have any._____________________________________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____Not at all.___________________________________________________________________________________________
______________________________________________________________________________________________________

+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?
How much?(specify daily amount)
Smoked cigarettes.
1.5 packs a day

Yes
No
For how many years? 30 years
(age 15 thru 45

If applicable, when did the

patient quit? 1/12/2012

Pack Years: 45 years

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

Has the patient ever tried to quit? Yes

If yes, what did they use to try to quit? Nicotine patches

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Beer and liquor
How much? 6 cans of beer
Volume:
Frequency: every weekend
If applicable, when did the patient quit?
At age 43.

No
For how many years?
(age

17

thru

43

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? Smoked marijuana
How much?
For how many years? 10
(age 22 thru
32
)
Refuses to say
Is the patient currently using these drugs?
Yes No

If not, when did he/she quit?

15 years ago

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014

 10 REVIEW OF SYSTEMS NARRATIVE

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

Be sure to answer the highlighted area

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? N/A
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- Lasix
kidney stones
Normal frequency of urination:
Bladder or kidney infections

4/day

Hematologic/Oncologic

Metabolic/Endocrine
1/day
1/year

Diabetes
Type: 2
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? 2/4/2015
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 2/6/2015

Central Nervous System

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

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox

University of South Florida College of Nursing Revision September 2014

Other:

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs? 10
Time frame? 1 week
Intentional? No (due to fluid retention)
How do you view your overall health? Im not very healthy, I know.

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 September 2014

10 PHYSICAL EXAMINATION:
General Survey: A&O
Height: 57
Weight: 296lbs
BMI: 46.4
Pain: (include rating and
times 3. Pt. seems
location) N/A
Pulse: N/A
MAP: 86 (VAD patient)
nourished and groomed.
Respirations: 16
Temperature: (route
SpO2 97%
Is the patient on Room Air or O2
Oxygen on 4L
taken?) 98.4 orally
and Bipap
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
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Midline Location:
Right AC
Date inserted: 2/6/2015
Fluids infusing?
no
yes - what? Lasix

flat
loud

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 3/ mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 8
inches & left ear- 8
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: In good repair, oral cleaning needed.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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: Clear and equal bilaterally
RUL
LUL
RML
LLL
RLL

Chest expansion

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

University of South Florida College of Nursing Revision September 2014

10

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

No JVD

Patient has a VAD (Heartmate II). Heart sounds are not audible.

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema: 2+
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: Legs and arms
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
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 2 / 5 / 15
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present:
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

GU
Urine output:
Clear
Cloudy
Color: light yellow
Previous 24 hour output: 2,975 mLs
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Musculoskeletal: 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 paresthesia
(No Pulses)
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

University of South Florida College of Nursing Revision September 2014

11

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
Blood Potassium

Dates

Chest X-ray

2/4/15

Accucheck

2/4/15
2/5/15
2/6/15

2/5/15
2/6/15

Trend
3.2
3.3
Congestive Heart Failure
and pulmonary edema
258
272
250

Analysis
Pt.s potassium is low and
needs to be replaced.
VAD is placed correctly.
Blood sugar is
continuously high.
Continue to monitor
levels and watch diet.

+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.)
Midline placement, Accucheck, continuous pulse ox, Bipip machine
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Inefficient breathing pattern related to patient not breathing out fully as evidenced by a high level of CO2 and
a low SPO2 when not on the Bipap machine.
2. At risk for activity intolerance related to being obese as well as having an inefficient breathing pattern.
3.
4.
5.

University of South Florida College of Nursing Revision September 2014

12

 15 CARE PLAN
Nursing Diagnosis: Inefficient breathing pattern related to patient not breathing out fully as evidenced by a high level of CO2 and a low SPO2 when not on the
Bipap machine.

Patient Goals/Outcomes
Demonstrate a breathing pattern
that supports healthy blood gas
levels.

Identify and avoid specific factors

that exacerbate episodes of
inefficient breathing.
Keep SPO2 level above 92% at all
times. (92% is low, but for this
patient, it was approved by
respiratory therapists)

Nursing Interventions to Achieve

Goal
Monitor oxygen saturation
continuously using pulse oximetry
and take ABGs. Have patient use
oxygen, incentive spirometer,
Bipap machine, or whatever tools
will help them.
Assist the patient with identifying
factors that exacerbate episodes of
ineffective breathing patterns like
stress, allergens, and certain
activities.
Use continuous pulse oximetry, use
the Bipap machine continuously,
and use oxygen while moving
around at 3L.

Rationale for Interventions

Provide References
An oxygen saturation less than
90% indicates a significant
oxygenation problem. Some
patients will not be able to breathe
efficiently enough on their own
however (NANDA, 2011).
Awareness of precipitating factors
helps the client to avoid them and
decreases their chance of having
ineffective breathing episodes
(NANDA, 2011).
Oxygen administration helps to
correct hypoxemia, which has
shown to cause dyspnea (NANDA,
2011).

Evaluation of Goal on Day Care

is Provided
A reading of 97% was attained
occasionally, but the ABGs came
back with a constantly high CO2
level, so the patient is not breathing
out fully.
Patient found that ambulation was
too much activity and caused he to
become very out of breath.
Due to the VAD, blood circulation,
along with oxygen circulation was
not great, so he would get an
occasional reading above 95, but a
majority of the time he would desat
below 80%.

Include a minimum of one

Long term goal per care plan
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- Diabetes and Heart healthy
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription- Teach importance of compliance
are any of the patients medications available at a discount pharmacy? Yes No
University of South Florida College of Nursing Revision September 2014

13

Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

14

References

McLeod. S. A. (2008). Erik Erikson. (n.d.). Simply Psychology. Retrieved June 23, 2014, from
http://www.simplypsychology.org/ Erik-Erikson.html
Huether, S. E., & McCance, K. L. (2008). Alterations of Hormonal Regulation.Understanding
Pathophysiology (Fifth Edition ed., ). St. Louis, Mo.: Mosby/Elsevier.
Ackley, B. J. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.).
Maryland Heights, Mo.: Mosby.

University of South Florida College of Nursing Revision September 2014

15

University of South Florida College of Nursing Revision September 2014

16

University of South Florida College of Nursing Revision September 2014

17