UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jeanne Zamith
Assignment Date: 03/02/2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: LRH
1 PATIENT INFORMATION
Patient Initials: GH Age: 82 Admission Date: 03/02/2017
Gender: M Marital Status: Married Primary Medical Diagnosis: CHF
Primary Language: English
Level of Education: High School graduate Other Medical Diagnoses: (new on this admission)
Internal hemorrhoids
Occupation (if retired, what from?): Retired; construction and military Number/ages children/siblings: Children: 1
daughter; age 53 & 1 sister: Died at age 78
Served/Veteran: Yes Code Status: Full resuscitation
If yes: Ever deployed? Yes; Korean War
Living Arrangements: Living with wife in a one-story home. Advanced Directives: Wife
Culture/ Ethnicity /Nationality: Caucasian Surgery Date: None
Procedure: Bleeding screen
Religion: Baptist Type of Insurance: Medicare

1 CHIEF COMPLAINT:
Patient stated that his stool looked like blueberry jello and progressively became redder throughout the day.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCARTS the symptoms in addition to the hospital course
of stay)
Patient is an 82-year-old white male admitted to the Emergency Department on Wednesday, March 1 at 1753 as
result of a gastrointestinal bleed that began at around 1100 that morning. According to the patient and his wife, the
stool looked like blueberry Jell-O clots and then advanced to bright red stool as the day progressed. Patient stated
nothing made the bleeding worse or better, which is why [I] decided to come to the emergency room. Patient
denies any previous history of GI bleeding and denied having any pain associated with the bleeding. Patient was
discharged two days ago, 02/27, from a COPD exacerbation and was readmitted yesterday for another cause.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
1983 HTN: No hospitalizations; carvedilol prescribed
1993 COPD: 4 hospitalizations for exacerbations; breathing treatment (Atrovent and predisone) prescribed;
PCP advised smoking cessation
06/2009 Lung cancer: CyberKnife treatment used
02/2013 CHF: Multiple hospitalizations; furosemide prescribed (along with continuing carvedilol for HTN)
04/2014 Atrial Fibrillation: No hospitalizations; No pharmacologic intervention

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2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)
FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause

Alcoholism
MEDICAL

Glaucoma

Problems

Problems
Allergies
of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY

Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 77 MI
Mother 81 CHF
Sister 78 CHF
Comments: Include age of onset
Father: Patient was unable to recall the onset of his fathers medical conditions.
Mother: Patient was unable to recall the onset of his mothers medical conditions.
Sister: Patient stated that his sisters heart issues began shortly after his.

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? 02/29/2017
Influenza (flu) (Date) Is within 1 years? 08/31/2016
Pneumococcal (pneumonia) (Date) Is within 5 years? 02/29/2017
Have you had any other vaccines given for international travel or
occupational purposes?

1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
Levaquin Joint swelling and trouble walking
Amlodipine Edema
Medications/other Compazine Confused and combative
Penicillin SOB and urticaria
Sensitive to tape Patients skin tears
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)
According to Treas and Wilkinson (2010), heart failure is defined as a loss or dysfunction of the cardiac muscle, causing the
ventricles to become unable to fill or eject blood, thus, making the heart unable to supply the bodys metabolic needs. This chronic
condition causes heart failure patients to present with inability to tolerate activities, fluid retention, and fatigue. The most common
causes of heart failure include hypertension, coronary artery disease, and dilated cardiomyopathies. Other risk factors include
environmental exposure, age, obesity, sedentary lifestyle, diabetes, hyperlipidemia, and smoking. Two different processes may lead to
heart failure, systolic and diastolic dysfunction. Both may occur simultaneously and can result in similar symptoms. Systolic
dysfunction is characterized by volume overload and decreased contractility (Treas & Wilkinson, 2014). Once this occurs, the heart
is no longer able to eject enough blood to meet the bodys demands, which can lead to right, left, and/or biventricular heart failure.
Diastolic dysfunction is characterized by elevated filling pressures with preserved left ventricular ejection fraction. Once the disease
progresses, it can be known as chronic heart failure. These patients usually present with anorexia, dyspnea, fatigue, nausea, vomiting,
and slow changes in their ability to perform activities of daily living (Treas & Wilkinson, 2014). Assessments may show a confused
patient due to low cardiac output, thus, poor cerebral perfusion. Genetic factors include family members with: CAD, HTN, DM,
sudden cardiac death, cardiomyopathies, or PVD. Though incurable, pharmacologic management has been shown to have clear
benefits both in prognosis and quality of life. Treatment for heart failure includes: alleviating symptoms, improving perfusion,
increasing activity tolerance, improving quality of life, and minimizing risk factors. Medications such as ACE-Inhibitors, ARBs, Beta-
Blockers, Diuretics, Aldosterone Antagonists, Antiarrhythmic agents, anticoagulant agents, and inotropic agents are combined to
University of South Florida College of Nursing Revision September 2014 2
create a regimen, providing the best quality of life possible. Implantable cardioverter defibrillators are also available for later stages of
the disease process. Heart failure follows a predictable course; patients usually start with stable symptoms and then progress to
episodes of exacerbations, which leave the patient unable to regain the same functional stability as prior. These exacerbations become
more common over time, usually making stabilization difficult and eventually leading to death (Treas & Wilkinson, 2010).

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

Name: prednisone (Rayos) Concentration: 20 mg Dosage Amount: 20 mg (1 tablet)

Route: PO Frequency: q24h

Pharmaceutical class: corticosteroid Home Hospital or Both
Indication: COPD inflammation
Adverse/ Side effects: insomnia, increased appetite, mood changes, slow wound healing, ecchymosis, cushingoid appearance, adrenal suppression, weight gain
Nursing considerations/ Patient Teaching: Advise patient to not stop taking the drug suddenly; assess I+Os; encourage patient to eat a diet high in protein, calcium,
and potassium and low in sodium and carbohydrates; educate patient about immunosuppression side effect

Name: carvedilol (Coreg) Concentration: 6.25 mg Dosage Amount: 6.25 mg (1 tablet)

Route: PO Frequency: q12h

Pharmaceutical class: Beta Blocker; antihypertensives Home Hospital or Both

Indication: Hypertension
Adverse/ Side effects: Dizziness, fatigue, weakness, diarrhea, hyperglycemia, angioedema, bradycardia, dry eyes, blurred vision
Nursing considerations/ Patient Teaching: Advise patient to stand/sit up slowly to avoid orthostatic hypotension; monitor BP and pulse frequently

Name: furosemide (Lasix) Concentration: 40 mg Dosage Amount: 40 mg (1 tablet)

Route: PO Frequency: q12h

Pharmaceutical class: Diuretic Home Hospital or Both
Indication: Edema due to HF + HTN
Adverse/ Side effects: Hyponatremia, hypokalemia, hyperglycemia, headaches, dizziness, hypotension, dehydration, hypovolemia
Nursing considerations/ Patient Teaching: Advise patient to stand/sit up slowly; assess pt.s fluid status frequently; monitor BP and pulse; advise patient to contact
HCP of weight gain more than 3 lbs in 1 day

Name: ipratropium (Atrovent) Concentration: 500 mcg Dosage Amount: 500 mcg

Route: NEB Frequency: q4h

Pharmaceutical class: Long-acting bronchodilator Home Hospital or Both
Indication: COPD
Adverse/ Side effects: headache, dizziness, hypotension, cough, back pain, dry mouth, nasal dryness/irritation
Nursing considerations/ Patient Teaching:

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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? Clear
Diet patient follows at home? Cardiac diet
24 HR average home diet:
Breakfast: Patient claims that he usually eats eggs, pancakes, and fresh fruit for breakfast.
Lunch: Grilled chicken sandwich and a bowl of fruit
Dinner: Grilled chicken, green beans, potatoes, and strawberries
Snacks: Patients wife stated that he eats Butterfinger bites like its nobodys business.
Liquids: Water or Gatorade
Analysis of home diet (Compare to My Plate and Consider co-morbidities and cultural considerations):
Considering the patient is in stage IV CHF, it is important that the patient follows a diet low in sodium. The patients
typical means consist of proteins, fruits, and some vegetables, which all have minimal sodium. Patient states that his wife
is the one that mainly manages his diet because, according to the patient, shes the one that cooks, so she gets to decide
what I eat. Patients wife stated that she understands the severity condition and takes the home diet very seriously.
Looking at the diet as a whole, the patient could eat more vegetables because they usually promote heart health and he is
only eating 51% of the recommended amount. The client could also minimize his intake of butterfingers because of the
excessive amounts of sugar, which is not beneficial for any condition. All foods considered, the patients diet does follow
pretty closely to a cardiac diet.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill?
My bride
How do you generally cope with stress? or What do you do when you are upset?
Patient stated I generally dont really get all that stressed. When hes upset, patient stated I just go to my wife, and she
knocks some sense into me.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient stated that his wife was recently diagnosed with an aneurysm between her heart and lung and the doctor said it
could rupture any minute, killing her instantly.

+2 DOMESTIC VIOLENCE ASSESSMENT

Have you ever felt unsafe in a close relationship? No, Ive been with the love of my life since middle school.
Have you ever been talked down to? Patient stated that he was talked down to in the army plenty of times, but has
never been talked down to by his wife.
Have you ever been hit punched or slapped? My wife has slapped me a few times, but I definitely deserved it.
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? Yeah, Id say so.

4 DEVELOPMENTAL CONSIDERATIONS:

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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:

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
GH is an 82 year old male, so the ego integrity vs despair stage would be most appropriate. The patient showed more
signs of the ego integrity stage rather than despair. He was not showing a sense of loss, discomfort with life and aging,
and fear of death, usually associated with the despair stage (Treas & Wilkinson, 2014). The patient seems to have few
regrets and understands that he is close to the end of his life.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The patient states that he knows he is close to passing away but still wants to travel more and spend more time
outside, but his condition limits his mobility and ability to do the things he wants to in his last days. GH believes
this disease has taught him to cherish the moments he has left with his wife and family.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient stated Im just an old man now. Im sure smoking for my whole life had something to do with it, too.

What does your illness mean to you?

Patient stated that this illness means hes closer to seeing Heaven but also closer to being without his wife.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Have you ever been sexually active? Yes.
Do you prefer women, men or both genders? Patient has a wife.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? N/A
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? Only when my wife lets me be.
If yes, are you in a monogamous relationship? Yes, for almost 70 years.
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or
an unintended pregnancy? Patient claims he does not prevent acquiring an STD, but he is in a monogamous
relationship.
How long have you been with your current partner? 70 years
Have any medical or surgical conditions changed your ability to have sexual activity? The patient claimed
that hes afraid of his wifes aneurysm. He also stated his chronic SOB from CHF have changed his sexual
activity.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or
unintended pregnancy? No.

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1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Patient claimed that he believes in God, which helps him to be at peace about his prognosis.
Do your religious beliefs influence your current condition?
I guess it probably puts me a little bit more at ease about dying than others.

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

SMOKING:
Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes, quit 2 years ago.
If so, what? Cigarettes
How much? (specify daily amount) 2 packs/day
Pack Years: 949,000
For how many years? 65
If applicable, when did the patient quit? About 2 years ago
Does anyone in the patients household smoke tobacco? No, my wife stopped many
years ago
If so, what, and how much? N/A
Has the patient ever tried to quit? Yes.
If yes, what did they use to try to quit? The doctors told me I had to stop, so I did.

ALCOHOL:
Does the patient drink alcohol or has he/she ever drank alcohol? Yes, patient was an alcoholic for about 15 years.
What? Beer
How much? Patients wife stated she could not keep track of how much he was drinking, especially after he came back
from the Korean War.
For how many years? About 15 years
Frequency? Patient stated he would drink when he was happy or sad, it didnt matter the occasion.
If applicable, when did the patient quit? Patient quit when he was forty years old.

CHEMICAL USE:
Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No
If so, what? Did not ask because patient stated that he had never tried the specified substances.
How much? Did not ask because patient stated that he had never tried the specified substances.
For how many years? Did not ask because patient stated that he had never tried the specified substances.
Is that patient currently using drugs? Did not ask because patient stated that he had never tried the specified
substances.
When did the patient quit? Did not ask because patient stated that he had never tried the specified substances.

Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient stated that he was most likely exposed to hazards/risks when he was fighting overseas. He was also a construction
worker for many years, so he was out in the sun most of the day.
For Veterans: Have you had any kind of service related exposure?
Patient stated that he was exposed to agent orange.

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 10 REVIEW OF SYSTEMS NARRATIVE
Integumentary Gastrointestinal Immunologic
Changes in appearance of skin: Paper
Nausea, vomiting, or diarrhea Chills with severe shaking
thin skin
Problems with nails Constipation Irritable Bowel Night sweats
Dandruff GERD Cholecystitis Fever
Psoriasis Indigestion Gastritis / Ulcers HIV or AIDS
Hives or rashes (FROM ALLERGIES
Hemorrhoids Blood in the stool Lupus
TO MEDS)
Skin infections Yellow jaundice Hepatitis Rheumatoid Arthritis
Use of sunscreen SPF: 40 Pancreatitis Sarcoidosis
Bathing routine: Every other day Colitis Tumor: Lung cancer
Diverticulitis Life threatening allergic reaction
Appendicitis Enlarged lymph nodes
HEENT Abdominal Abscess Other: Patient denied other issues.
Difficulty seeing: Wears glasses Last colonoscopy? 03/2017
Cataracts or Glaucoma Other: Patient denied other issues. Hematologic/Oncologic
Difficulty hearing Anemia
Ear infections Genitourinary Bleeds easily
Sinus pain or infections nocturia Bruises easily
Nose bleeds dysuria Cancer
Post-nasal drip hematuria Blood Transfusions
Oral/pharyngeal infection oliguria Blood type if known: A+
Dental problems: dentures kidney stones Other: Patient denied other issues.
Routine brushing of teeth: 2x/day Normal frequency of urination: 3/day
Bladder or kidney infections: Chronic
Routine dentist visits: 2x/year Metabolic/Endocrine
UTIs
Vision screening: 1x/year Diabetes Type:
Other: Patient denied other issues. WOMEN ONLY Hypothyroid/Hyperthyroid
Infection of the female genitalia Intolerance to hot or cold
Pulmonary Monthly self breast exam Osteoporosis
Difficulty Breathing Frequency of pap/pelvic exam Other: Patient denied other issues.
Cough - dry or productive Date of last gyn exam?
Asthma menstrual cycle regular irregular Central Nervous System
Bronchitis menarche age? CVA
Emphysema menopause age? Dizziness
Pneumonia Date of last Mammogram & Result: Severe Headaches
Tuberculosis Date of DEXA Bone Density & Result: Migraines
Environmental allergies Seizures
last CXR? 02/2017 MEN ONLY Ticks or Tremors
Other: Patient denied other issues. Infection of male genitalia/prostate? Encephalitis
Frequency of prostate exam? 1x/year Meningitis
Cardiovascular Date of last prostate exam? 12/2016 Other: Patient denied other issues.
Hypertension BPH
Hyperlipidemia Urinary Retention Mental Illness
Chest pain / Angina Depression
Myocardial Infarction Musculoskeletal Schizophrenia
CAD/PVD Injuries or Fractures Anxiety
CHF Weakness Bipolar
Murmur Pain Other: PTSD
Thrombus Gout
Rheumatic Fever Osteomyelitis Childhood Diseases
Myocarditis Arthritis Measles
Arrhythmias Other: Patient denied other issues. Mumps
Last EKG screening, when? 01/2017 Polio
University of South Florida College of Nursing Revision September 2014 7
 Other: Patient denied other issues. Scarlet Fever
Chicken Pox
Other: Patient denied other issues.

General Constitution
Recent weight loss or gain
How many lbs? I usually lose 3-4 lbs on and off
Time frame? 2 years
Intentional? No
How do you view your overall health? I have a lot of issues.

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient also has atrial fibrillation.
Any other questions or comments that your patient would like you to know?
Patient denied having any questions.

10 PHYSICAL EXAMINATION:

General Survey: A & O x3 Height: 6 1 Weight: 212 pounds BMI: 28 Pain (include rating and
Vitals: 03/02 @ 0948 Pulse: 108 110 Blood Pressure: (include location): location): Patient is
03/02 @ 1246 RR: 1818 123/66 124/65 currently in no pain.
Temperature: (route SpO2: 93% 92% Is the patient on Room Air or O2
taken?) 98.2F 98.8F 4L of O2
ORAL

Overall Appearance: [Dress/grooming/physical handicaps/eye contact]

clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant cooperative cheerful talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:

Integumentary
Skin is warm, dry, and intact Skin turgor elastic No rashes, lesions, or deformities
Nails without clubbing Capillary refill < 3 seconds Hair evenly distributed, clean, without vermin
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: Location: Date inserted:
Fluids infusing? no yes - what?
Comments: Patients skin is fragile and tears easily. Tenting is present. Rashes are present due to the tape. Clubbing is
present due to chronic hypoxia r/t COPD. Capillary refill was 5 seconds. Hair was not present on the legs.

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/mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: *Did not assess*
University of South Florida College of Nursing Revision September 2014 8
 Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Dentures well-kempt
Comments: No comments

Pulmonary/Thorax: Respirations regular and unlabored Transverse to AP ratio 2:1 Chest expansion
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production; Amount: not being measured
Color: Clear
Lung sounds: Wheezing and crackles present in all regions.
RUL: CR and WH present LUL: CR and WH present
RML: CR and WH present LLL: CR and WH present
RLL: CR and WH present
(CL Clear; WH Wheezes; CR Crackles; RH Rhonchi; D Diminished; S Stridor; Ab Absent)
Comments: Patients respirations were irregular and slightly labored. Unable to determine whether the lungs percussed resonant, but
due to the fluid accumulation, I would assume the sound would be on the dull side.

Cardiovascular: No lifts, heaves, or thrills

Heart sounds: S1 S2 audible Regular Irregular No murmurs, clicks, or adventitious heart sounds No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze): Did not print 6 second strip; atrial
fibrillation indicated.
Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 4 Brachial: 2 Radial: 1 Femoral: 2 Popliteal: 1 DP: 1 PT: 1
No temporal or carotid bruits Edema: +1 [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: N/A
Extremities warm with capillary refill less than 3 seconds
Comments: Heart rate was irregular, consistent with A fib. JVD was present s/t CHF. I believe I auscultated a murmur. Was
unable to determine whether a carotid bruit was present, but due to JVD, I would assume bruits would be present.

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: 03/02/2017) 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: N/A
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe: Stool color started off as coffee ground and progressed to bright red within hours. Stool is now back to
normal and peanut butter colored.

GU Urine output: Clear Cloudy Color: Pale yellow Previous 24 hour output: N/A
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 RUE: 4 LUE: 4 RLE: 3 LLE: 3
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
Vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

Neurological: Patient awake, alert, oriented to person, place, time, and date Confused; if confused attach mini mental exam
CN 2-12 grossly intact Sensation intact to touch, pain, and vibration Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with
intermittent or transient clonus]
University of South Florida College of Nursing Revision September 2014 9
Triceps: 2 Biceps: 2 Brachioradial: 2 Patellar: 2 Achilles: 2 Ankle clonus: negative Babinski: negative

Patient was unable to get out of bed due to SOB to complete the test for proprioception and the Rombergs test; however,
graphesthesia and stereognosis were intact.

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 Results Dates Trend Analysis (Pai & Fort, 2014).

BNP 9753 pg/mL 02/27/2017 Only one BNP lab BNP measures how well the heart is
(0.5-30 pg/mL) *Only one lab value available functioning and anything over 100
available* usually indicates heart failure. So GHs
BNP of 9753 confirms his diagnosis of
CHF.
Hgb 12.0 g/dL 03/01/2017 Hgb and Hct are Considering both the patients age and GI
(13.5-17.5 g/dL) 13.4 g/dL 03/02/2017 trending upwards, bleed, lower HNH levels would be
getting closer expected at first; however, they should
Hct 36.5% 03/01/2017 toward normal slowly rise after the GI bleed subsides,
(41%-49%) 43.7% 03/02/2017 values. which they are. Treatment is working.
Echocardiogram 35%; enlarged 02/26/2017 Only one A low ejection fraction proves that the
(EF: 55% -70%) atria and Echocardiogram test heart is unable to contract well enough to
ventricles was performed eject the blood out of the heart to the rest
*Only one lab of the body, thus, indicating heart failure.
available* The echocardiogram is also able to
determine the size of the atria and
ventricles. The enlargement further
showed the prognosis of his CHF.
Bleed Scan Negative 03/02/2017 Only one Bleed scan The bleed scan was scheduled to
test performed determine the source of the GI bleed;
however, it came back negative. The
health care team scheduled an endoscopy
to rule out possible hemorrhoids.
EKG Atrial Fibrillation 03/02/2017 Only one EKG This patients EKG was performed to
available confirm atrial fibrillation. Atrial
fibrillation causes blood to be unable to
fill properly, causing fluid overload in the
lungs. This combined with heart failure
indicates the severity of the symptoms the
patient is experiencing.

+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.)
GH is currently on clear liquid diet for the scheduled colonoscopy/endoscopy on 03/03/17 to rule out
possible hemmorhoids.. Patient is on continuous telemetry for atrial fibrillation. Patient is not on accu
checks. Patient is full ambulation. Respiratory therapy and dietician have been consulted.

University of South Florida College of Nursing Revision September 2014 10

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) (Ackley, 2007)

CHF:
1) Excess fluid volume r/t cardiac dysfunction and compromised regulatory mechanism aeb crackles upon
auscultation, +1 peripheral pitting edema, weight gain over a short period of time, blood pressure
changes, and intake exceeding cardiac output.
2) Decreased cardiac output r/t altered heart rate and rhythm aeb EF 35%, diagnosis of CHF, and diagnosis
of atrial fibrillation.
3) Ineffective breathing pattern r/t hypoventilation aeb dyspnea, nasal flaring, orthopnea, and alterations in
depth of breathing.
GI Bleed:
1) Fatigue r/t loss of circulating blood volume aeb coffee-ground stools that proceeded to bright red stools,
verbalization of lack of energy, and drowsiness.

15 CARE PLAN
Nursing Diagnosis: Excess fluid volume r/t cardiac dysfunction and compromised regulatory mechanism aeb
crackles upon auscultation, +1 peripheral pitting edema, weight gain over a short period of time, blood pressure
changes, and intake exceeding cardiac output (Ackley, 2007).

Patient Goals/Outcomes: (Ackley, 2007).

Patient will remain free of peripheral and/or pulmonary edema.
Patient will maintain as clear lung sounds as possible with no evidence of dyspnea or orthopnea.
Patient will verbalize actions that are needed to treat or prevent excess fluid volume, including fluid and
dietary restrictions.
Nursing Interventions + Rationales: (Ackley, 2007).
Nurse will monitor daily weights for sudden increases and use the same scale and type of clothing at the
same time each day, preferably before breakfast.
o Body weight changes reflect changes in body fluid volume.
When patient is able to resume a normal diet, nurse will provide a restricted sodium diet, if ordered.
o Restricting the sodium intake will allow for renal excretion of excess fluid.
Nurse will auscultate lung sounds for crackles, monitor respiratory effort, and determine presence of
orthopnea.
o Pulmonary edema results from excessive shifting of fluid from the vascular space into the
pulmonary interstitial space, resulting in dyspnea and orthopnea.
Nurse will administer diuretics as prescribed; check blood pressure before administration. Note urine
output following the dose and monitor electrolytes.
o Diuretics are used to help renal excretion of excess fluid. Clinical guidelines on heart failure
show that monitoring blood pressure and I&Os is useful for monitoring the effectiveness of the
diuretic.
Evaluation of Goal: (Ackley, 2007).
Patient received Lasix and the electrolytes are all within normal limits. Goal was met.
Patient verbalized a proper diet associated with congestive heart failure. Goal was met.
Nursing student auscultated lung sounds three times throughout the shift and still auscultated crackles.
Goal was not met.

University of South Florida College of Nursing Revision September 2014 11

Nursing Diagnosis 2: Ineffective breathing pattern r/t hypoventilation and pulmonary edema aeb dyspnea,
nasal flaring, orthopnea, and alterations in depth of breathing (Ackley, 2007).

Patient Goals/Outcomes: (Ackley, 2007).

Patient will demonstrate a breathing pattern that supports blood gas results within the patients normal
parameters.
Patient report fewer signs and symptoms of dyspnea.
Patient will verbalize specific factors that exacerbate episodes of ineffective breathing pattern.
Nursing Interventions + Rationales: (Ackley, 2007).
Nurse will monitor respiratory rate, depth, and ease of respiration.
o When the respiratory rate is lower than 12 breaths per minute, it puts the patient at risk for
respiratory acidosis.
Nurse will encourage patient to sit upright or stand to avoid lying down for prolonged periods
throughout the day.
o High-fowlers position allows for maximal lung expansion, thus, improving breathing pattern.
Nurse will monitor oxygen saturation continuously using pulse oximetry.
o Considering the nature of CHF/COPD, the edema may cause the patients oxygen saturation to
plummet.
Nurse will administer oxygen and breathing treatments as ordered.
o Oxygen administration has been shown to correct hypoxia; the breathing treatments will help
dilate pulmonary blood vessels and decrease inflammation, allowing for better gas exchange.
Nurse will assist the client and family with identifying other factors that precipitate or exacerbate
episodes of ineffective breathing patterns.
o Awareness of precipitating factors helps clients avoid them and decreases risk of ineffective
breathing episodes.
Evaluation of Goal: (Ackley, 2007).
Nurse monitored respiratory rate, depth, and ease of respiration and gave oxygen and breathing
treatments as needed.
Patient verbalized that too much activity exacerbates episodes of ineffective breathing patterns. Nurse
recommended separating activities in the morning (such as brushing teeth, showering, using the
restroom, etc.) and patient stated that he would use that method the next morning.
Nurse assisted patient to bedside chair to get some sunlight and to sit up-right in order to maximize lung
expansion.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would
include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments: PCP and Dr. Saco (GI specialist)
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 12

 References

Ackley, B. J., Ladwig, G. B., & Elsevier, c2008. (2007). Nursing diagnosis handbook: An Evidence

Based Guide to Planning Care (8th ed.). Edinburgh: Elsevier Mosby.

Choose MyPlate. (2016, January 12). Retrieved October 26, 2016, from Choose MyPlate,

https://www.choosemyplate.gov/

Commane, D. (2009). Diet, Ageing and Genetic Factors in the pathogenesis of diverticular

disease. World Journal of Gastroenterology,15(20).

Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical Surgical Nursing: Preparation for

Practice. Boston: Pearson.

Pai, R. K., & Fort, S. (2014). Laboratory tests for heart failure. Retrieved from:

http://www.uofmhealth.org/health-library/hw41813

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills, and Reasoning. Philadelphia,

PA: F.A Davis Company, 164.

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University of South Florida College of Nursing Revision September 2014 14