UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Rebecca Netjes

Assignment Date: 07/12/2016
.
Agency: Florida Hospital Tampa
 1 PATIENT INFORMATION
Patient Initials: MY Age: 76 years old Admission Date: 06/21/2016
Gender: Female Marital Status: Widowed Primary Medical Diagnosis: Fluid Overload
related to exacerbation of Congestive Heart Failure
Primary Language: English
Level of Education: Patient stated they received some college Other Medical Diagnoses: (new on this
education, but is unsure of what degree they obtained. admission)
No new diagnoses on this admission. Patient is
receiving treatment for exacerbation of several
Occupation (if retired, what from?): Patient is retired from an chronic conditions.
administrative position at Hillsborough Community College.
Number/ages children/siblings: Patient has no children, but one
brother and four sisters. She stated they are “all above 55 years
old”.
Served/Veteran: No Code Status: Full Resuscitation
If yes: Ever deployed? Yes or No: Not applicable
Living Arrangements: Patient lives at home with her sister and Advanced Directives: Patient has a living will and
brother in law. Patient states that her home is “nearby to all of her medical durable power of attorney. Both of these
doctors, which makes it very convenient for her family”. documents are on file at the hospital.
Surgery Date: not applicable
Procedure: Coronary Catheter placed 6/27/16,
Dialysis began 6/28/16
Culture/Ethnicity/Nationality: Caucasian
Religion: Baptist Type of Insurance: Medicare and AARP

 1 CHIEF COMPLAINT:
Patient was brought the hospital on 6/21/16 by her sister because she was experiencing “difficulty breathing, chest pain
and pressure, as well as neck pain”. The patient’s sister stated that she had gained 10 pounds in 5 days as well exhibited
some hallucinatory symptoms. She was “picking at bugs on her skin and blankets”. Patient was at a surgery center for a
visit prior to placement of a coronary catheter, but was brought to FHT for evaluation of symptoms.

 3 HISTORY OF PRESENT ILLNESS:

MY is a 76-year-old female with frequent admissions to FHT for exacerbation of her many chronic health conditions. On
6/21/16, the patient was admitted for evaluation of shortness of breath, weight gain, and erythema/edema in her lower
extremities. The patient was also, per her sister, hallucinating and imagining that there were insects on her skin. After her
admission, it became clear that the patient’s treatment regimen for congestive heart failure (CHF) and hypertension (HTN)
needed to be re-evaluated as she was having frequent episodes of exacerbation. The hallucinatory symptoms resolved
within a 3-4 days of her admission. After her admission, the patient also began to develop some symptoms of anxiety,
such as crying or having uncontrollable sadness. The anxiety lasted from 6/21/16 to 6/27/16, but was not constant
throughout each day. Her episodes of grief were resolved with rest and care from the nursing staff. After 6/27/16, the
patient would experience mild, intermittent confusion until 7/4/16. A CT was done on 7/2/16 to rule out any brain

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 anomalies that could cause an acute mental status change. No anomalies were found, and within 2 days her symptoms of
anxiety subsided and the patient’s usual demeanor returned. Also, on 6/27/16 a coronary catheter was placed in the right
subclavian. The patient was started on dialysis on 6/28/16 to combat her worsening renal failure. The patient has tolerated
all sessions of dialysis well. No abnormalities in the procedure have been noted. She has experienced symptoms of
constipation or an impaction since being in the hospital. This began 7/7/16, but studies were done to rule out impaction.
The constipation continues to be a problem, but is resolving through the use of stimulant laxatives and stool softeners. For
the last 2 days, the patient has had several episodes of diarrhea. The patient will remain at FHT until the exacerbated
condition of her CHF, HTN, and renal failure improves. Her discharge will also be on the condition that her symptoms of
constipation improve.

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY

Date Operation or Illness

“within 10 years”
2011
“within 10 years”
2008
“within 10 years”
“within 10 years”
“within 10 years”
“within 10 years”
“within 10 years”
2011
1980s
“within 10 years”
Since birth
“within 10 years”
2011
2014
Chronic diastolic heart failure, congestive heart failure: managed with diuretics, nitroglycerin, and
dialysis
Aortic valve replacement: managed with clopidogrel, aspirin, and ivabradine
Stage IV renal failure: managed with dialysis
Carotid stenosis: treated by endarterectomy
Obstructive sleep apnea: treated with BiPAP
Chronic obstructive pulmonary disease: managed with budesonide-formoterol
Hypothyroidism: treated by thyroidectomy, managed with levothyroxine
Obesity: attempt to manage with diet
Essential hypertension: treated with diuretics and metoprolol
Pleural effusion: hospitalized, resolved
Hysterectomy
Hyperlipidemia: treated with atorvastatin
Murmur: innocent, no treatment, absent now
Gout: treated with allopurinol
Cardiac pacemaker insertion
Shingles: outbreak managed with OTC analgesic medication, resolved
*Patient was questioned regarding date of diagnosis, but patient was unaware, and stated “within 10
years”. Chart only contained specific years listed above.

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

Seizures
Arthritis
Anemia

Asthma

Kidney

HISTORY
Cancer

Tumor
Stroke
Death
Gout

(if
applicable)
Father CHF
Mother CHF
Brother
Sister
relationship

relationship

relationship

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Comments:
The patient’s father had coronary artery disease (secondary to hyperlipidemia), congestive heart failure, and diabetes. The patient’s
mother had rheumatoid arthritis, coronary artery disease, and congestive heart failure. The patient’s brother has coronary artery
disease, and has had a myocardial infarction and stroke. Her sister had diabetes and macular degeneration related to her age. Patient
stated “could not remember” any of the ages of onset nor ages of death.

 1 IMMUNIZATION HISTORY
YES NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) – Patient unaware of date, but state she “had the TDAP not
too long ago”.
Adult Tetanus (Date) - Patient unaware, but believes “it was within 10 years”.
Influenza (flu) (Date) - 11/16/15
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or occupational
purposes?
Patient does not know what specific vaccines she received, but states they were for trips
to Israel in her “younger days”. She did not recall her specific age or date of
immunization.

 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
darvocet A500 Intolerance: severe hallucinations
demerol Intolerance: severe hallucinations
dilaudid Intolerance: severe hallucinations
Medications
gabapentin Allergy: unknown
morphine Intolerance: severe hallucinations
tramadol Intolerance: unknown
adhesive tape Allergy: skin tears
Other (food, tape,
latex, dye, etc.)

 5 PATHOPHYSIOLOGY:

Congestive heart failure (CHF) is commonly known as left heart failure, and can be further divided into systolic heart
failure or diastolic heart failure. Systolic heart failure is characterized by “an inability of the heart to generate an adequate
cardiac output” which results in decreased peripheral perfusion (Huether, S. E., & McCance, K. L., 2012, p. 623).
Diastolic heart failure is associated with “preserved systolic function or heart failure with normal ejection fraction”
(Huether, S. E., & McCance, K. L., 2012, p. 625). The patient is diagnosed with diastolic heart failure. This disease
process is typically preceded with hypertrophy of the myocardial cells secondary to hypertension. As a result of this
hypertrophy, the cells do not appropriately pump calcium, so there is a delay in contraction. Many times, individuals with
CHF have accompanying renal dysfunction. This renal dysfunction often results in elevated sodium retention and
increased fluid volume, because of the inappropriate functioning of the renin-angiotensin-aldosterone system. This
frequently exacerbates the condition of CHF as the heart cannot cope with excessive fluid retention. It is not uncommon
for CHF patients to have a proceeding diagnosis of hyperlipidemia. This condition increases the likelihood of
atherosclerotic plaques in the arteries and veins. This phenomenon increases the possibility of myocardial ischemia

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leading to hypertrophy of the cells. Risk factors for CHF include hypertension, disease of aortic/mitral valve, diabetes,
hyperlipidemia, and renal dysfunction. Diagnosis typically focuses on the symptoms the patient is expected to present, left
ventricular ejection fraction, and proven diastolic dysfunction. Echocardiograms are often used to analyze ejection
fraction and diastolic function status. Medications such as “calcium channel blockers, beta-blockers, ACE inhibitors, and
ARBs have been used with varying success” (Huether, S. E., & McCance, K. L., 2012, p. 626). Patients may also be on
medications, such as diuretics, to combat symptoms of CHF, like peripheral edema. Prognosis of CHF patient is often
poor as the cardiac function decreases and arrhythmia increases. (Huether, S. E., & McCance, K. L., 2012)

 5 MEDICATIONS:

Reference: (Karch, A. M., 2016) and (Kee, J. L., Hayes, E. R., & McCuistion, L. E. 2015)

Name: acetaminophen/Tylenol Concentration: Dosage Amount: 650 mg

Route: oral Frequency: As needed every four hours

Pharmaceutical class: prostaglandin synthesis inhibitor Home Hospital or Both
Indication: As needed for pain or fever
Adverse/ Side effects: rash/hives/itching, swelling, hoarseness, difficulty breathing or swallowing, liver damage
Nursing considerations/ Patient Teaching: Do not take more than one medication containing acetaminophen at a time, do not take more than 4,000 mg in a day,
report history of liver disease, swallow the pill whole, monitor liver function tests

Name: albuterol-ipratropium/ DuoNeb Concentration: Dosage Amount: 3 ml

Route: inhalation Frequency: Two times a day via nebulizer

Pharmaceutical class: beta-2 agonist Home Hospital or Both
Indication: prevent wheezing/dyspnea/cough r/t chronic obstructive pulmonary disease (COPD)
Adverse/ Side effects: headache, shaking/nervousness, tachycardia, chest pain, hives/itching/rash, difficulty urinating, dizziness
Nursing considerations/ Patient Teaching: Report worsening symptoms to your doctor, avoid contact with the eyes, do not operate heavy machinery until you
know how the medication affects you

Name: allopurinol/Zyloprim Concentration: Dosage Amount: 100 mg

Route: oral Frequency: Two times a day

Pharmaceutical class: uric acid biosynthesis inhibitor Home Hospital or Both
Indication: gout
Adverse/ Side effects: upset stomach, diarrhea, drowsiness, rash, dysuria, hematuria, irritation of the eyes, anorexia, unexpected weight loss, itching
Nursing considerations/ Patient Teaching: Report history of kidney/liver/heart disease, caution as the medication can make you drowsy, increase fluids to at
least 8 glasses of water a day, encourage patient to have yearly eye exams

Name: aspirin/Ecotrin Concentration: Dosage Amount: 81 mg

Route: oral Frequency: At bedtime

Pharmaceutical class: nonselective COX inhibitor Home Hospital or Both
Indication: prevent clot formation (antiplatelet effects)
Adverse/ Side effects: nausea, vomiting, diarrhea, hearing loss, heartburn, tinnitus, GI bleeding, hepatotoxicity
Nursing considerations/ Patient Teaching: Do not take with alcohol or warfarin, inform dentist/surgeon of medication prior to procedure, do not give to
children, take with food and fluids, report side effects

Name: atorvastatin/Lipitor Concentration: Dosage Amount: 10 mg

Route: oral Frequency: At bedtime

Pharmaceutical class: HMG-CoA reductase inhibitor Home Hospital or Both
Indication: hyperlipidemia
Adverse/ Side effects: constipation, abdominal cramps, liver impairment, rhabdomyolysis, cataracts
Nursing considerations/ Patient Teaching: Check baseline kidney function, patient should not consume more than 2 alcoholic drinks a day while taking this
medication, take the medication at bedtime, report muscle pain/tenderness, teach importance of compliance to regimen, encourage yearly eye exams
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Name: azelastine nasal/Astepro Concentration: 137 mcg/inh Dosage Amount: 1 spray

Route: inhalation Frequency: As needed

Pharmaceutical class: antihistamine and mast cell stabilizer Home Hospital or Both
Indication: As needed for allergy symptoms
Adverse/ Side effects: bitter taste, tiredness, weight increase, muscle pain, nasal burning
Nursing considerations/ Patient Teaching: Teach patient appropriate technique for inhaler administration, teach patient of signs of severe allergic reaction that
require medical attention, assess nasal mucosa, use sugarless candy/gum/ice chips to relieve dry mouth

Name: bisacodyl/Dulcolax Laxative Concentration: Dosage Amount: 10 mg

Route: suppository Frequency: one time dose

Pharmaceutical class: stimulant laxative Home Hospital or Both
Indication: constipation
Adverse/ Side effects: stomach cramps, faintness, stomach discomfort, rectal bleeding
Nursing considerations/ Patient Teaching: Report any evidence of rectal bleed, encourage a high fiber diet and increased fluids, report worsening symptoms

Name budesonide-formoterol/Symbicort Concentration: 160 mcg-4.5 mcg/inh Dosage Amount: 2 Puff

Route: inhalation Frequency: 2 times a day

Pharmaceutical class: corticosteroid Home Hospital or Both
Indication: COPD
Adverse/ Side effects: dry mouth/nose, vomiting, nosebleeds, hives/rash/itching, chest tightening, swelling, difficulty breathing, weakness
Nursing considerations/ Patient Teaching: Keep the medication in the container it is packaged it, clean your spray trip periodically, increase fluids, do not
operate machinery until you know how this medication affects you

Name: bumetanide/Bumex Concentration: Dosage Amount: 2 mg

Route: oral Frequency: 3 times a day

Pharmaceutical class: loop diuretic Home Hospital or Both
Indication: edema, fluid overload
Adverse/ Side effects: hyponatremia, hypomagnesemia, hypochloremia, elevated BUN and creatinine, hyperlipidemia, orthostatic hypotension, ototoxicity,
hyperglycemia, blood dyscrasia
Nursing considerations/ Patient Teaching: Check to see if the patient is taking other ototoxic drugs, give potassium supplements as administered, limit alcohol,
daily weights

Name: cetirizine/Zyrtec Concentration: Dosage Amount: 10 mg

Route: oral Frequency: 1 tablet daily

Pharmaceutical class: H1-receptor antagonist Home Hospital or Both
Indication: “allergy symptoms”
Adverse/ Side effects: drowsiness, dry mouth, tachycardia, mild hypotension, constipation, photosensitivity
Nursing considerations/ Patient Teaching: Obtain a list of environmental allergens, give with food to reduce GI distress, do not operate heavy machinery until
you know how the medication affects you avoid CNS depressants, use sugarless candy/gum/ice chips to relieve dry mouth

Name: clopidogrel/Plavix Concentration: Dosage Amount: 75 mg

Route: oral Frequency: 1 tablet daily

Pharmaceutical class: ADP receptor blocker Home Hospital or Both
Indication: prevent platelets synthesis thereby preventing clot formation

Adverse/ Side effects: bleeding, nausea, vomiting, rash/itching, life threatening hemorrhage, neutropenia, hepatotoxicity
Nursing considerations/ Patient Teaching: Check baseline platelet count, take with meals or full glass of water, give 1 hour before or 2 hours after antacids,
report signs of bleedings (i.e. bruising)

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Name: diphenhydramine/Benadryl Concentration: Dosage Amount: 25 mg

Route: oral Frequency: As needed 3 times a day

Pharmaceutical class: H1-receptor antagonist Home Hospital or Both
Indication: As needed for itching
Adverse/ Side effects: drowsiness, dry mouth, tachycardia, mild hypotension, constipation, photosensitivity
Nursing considerations/ Patient Teaching: Obtain a list of environmental allergens, give with food to reduce GI distress, do not operate heavy machinery until
you know how the medication affects you avoid CNS depressants, use sugarless candy/gum/ice chips to relieve dry mouth

Name: duloxetine/Cymbalta Concentration: Dosage Amount: 60 mg oral delayed release

capsule
Route: oral Frequency: 1 capsule daily
Pharmaceutical class: serotonin-norepinephrine reuptake inhibitor Home Hospital or Both
Indication: Nerve pain
Adverse/ Side effects: drowsiness, dizziness, insomnia, headache, confusion, blurry vision, nausea, decreased libido, risk for serotonin syndrome, seizures,
suicidal thoughts
Nursing considerations/ Patient Teaching: Do not crush or chew capsules, take exactly as directed/do not double dose, avoid alcohol, do not discontinue suddenly

Name: furosemide/Lasix Concentration: Dosage Amount: 80 mg

Route: oral Frequency: 1 tablet 2 times a day

Pharmaceutical class: loop diuretic Home Hospital or Both
Indication: Fluid retention
Adverse/ Side effects: hyponatremia, hypomagnesemia, hypochloremia, elevated BUN and creatinine, hyperlipidemia, orthostatic hypotension, ototoxicity,
hyperglycemia, blood dyscrasia
Nursing considerations/ Patient Teaching: Check to see if the patient is taking other ototoxic drugs, give potassium supplements as administered, limit alcohol,
daily weights

Name: guaifenesin/Mucinex Concentration: Dosage Amount: 600 mg oral tablet, extended

release
Route: oral Frequency: 1 tab daily
Pharmaceutical class: expectorant Home Hospital or Both
Indication: cough
Adverse/ Side effects: headache, nausea, vomiting, diarrhea, hives/rash, stomach pain
Nursing considerations/ Patient Teaching: Do not crush or chew tablet, swallow with a full glass of water, instruct the patient to report a rash/high
fever/headache that does not relieve

Name: heparin/Hep-Lock Concentration: Dosage Amount: 5,000 units

Route: subcutaneous injection Frequency: Every 12 hours

Pharmaceutical class: thrombin synthesis inhibitor Home Hospital or Both
Indication: Prevent clot formation
Adverse/ Side effects: bleeding, abdominal pain, constipation, nausea/vomiting, hyperkalemia, heparin-induced thrombocytopenia
Nursing considerations/ Patient Teaching: Check aPTT, teach patient proper subcutaneous administration, do not rub area of injection afterward, teach patient
to report injuries immediately for risk of bleeding, do not take aspirin containing products, heparin is safe to use during pregnancy

Name: hydralazine/Apresoline Concentration: Dosage Amount: 25 mg

Route: oral Frequency: As needed 4 times a day

Pharmaceutical class: arterial vasodilator Home Hospital or Both
Indication: As needed for itching
Adverse/ Side effects: dizziness, hypotension, tachycardia, hypernatremia
Nursing considerations/ Patient Teaching: Monitor last blood pressure before and after giving the medication, teach patient to stand slowly after administration
of medication, older adults may require a lower dose due to increased sensitivity

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Name: ivabradine/Corlanor Concentration: Dosage Amount: 5 mg

Route: oral Frequency: 1 tablet 2 times a day

Pharmaceutical class: cyclic nucleotide-gated channel blocker
Home Hospital or Both
Indication: Stabilize heart dysrhythmia related to heart failure
Adverse/ Side effects: tachycardia/bradycardia, chest pain, shortness of breath, fatigue, swelling, difficulty swallowing
Nursing considerations/ Patient Teaching: Teach patient to report all medications/herbal products to provider as there are multiple drug interactions, report
irregular heartbeat or blood pressure, do not consume grapefruit juice

Name: levothyroxine/Synthroid Concentration: Dosage Amount: 50 mcg

Route: oral Frequency: Once daily

Pharmaceutical class: thyroid hormone preparations Home Hospital or Both
Indication: Thyroid hormone replacement
Adverse/ Side effects: tachycardia (especially with first dose), hypertension, warm skin, insomnia, nervousness, increased bowel movement, weight loss, angina,
myocardial infarction, heart failure, seizure, thyroid crisis
Nursing considerations/ Patient Teaching: Always give the same drug brand the patient usually takes, give medication at the same time the patient usually takes
it, monitor heart rate/rhythm (especially in first dose), teach patient symptoms of hyperthyroidism and what to report, teach patient to take the medication 2-3
hours before or 4 hours after dietary fiber supplements

Name: metoprolol/Lopressor Concentration: Dosage Amount: 25 mg

Route: oral Frequency: 1 tablet 2 times a day

Pharmaceutical class: beta-1 receptor blocker Home Hospital or Both
Indication: hypertension
Adverse/ Side effects: impotence, dizziness, insomnia, lethargy, nightmares, bradycardia, chest pain, dyspnea, seizures, masked hypoglycemia, exacerbation of
asthma, rebound hypertension if stopped abruptly
Nursing considerations/ Patient Teaching: Always check heart rate and blood pressure before medication administration, teach patient to report history of
asthma, teach patient not to discontinue quickly as they may experience a myocardial infraction or rebound hypertension, teach patient to rise slowly as the first
does can cause orthostatic hypotension

Name: nitroglycerin/Nitrostat Concentration: Dosage Amount: 0.4 mg

Route: sublingual Frequency: As needed, every 5 minutes

Pharmaceutical class: nitrates/venous vasodilator Home Hospital or Both
Indication: Chest pain
Adverse/ Side effects: headache, hypotension, dizziness, tachycardia
Nursing considerations/ Patient Teaching: Check blood pressure before medication administration, teach patient that headaches are common at first and they
can treat with acetaminophen (unless otherwise contraindicated), patient should be taught proper sublingual administration, patient should call 911 if the pain
worsens after one dose or is not relieved with three doses in fifteen minutes

Name: pantoprazole/Protonic Concentration: Dosage Amount: 40 mg

Route: oral Frequency: 1 tablet daily

Pharmaceutical class: proton pump inhibitor Home Hospital or Both
Indication: reflux
Adverse/ Side effects: headache, joint pain, constipation, blistering skin, tachycardia, lightheadedness, seizures, severe diarrhea, increased likelihood of
fractures, weakening of stomach lining, and vitamin B12 deficiency
Nursing considerations/ Patient Teaching: Nurses should assess for a history of H. pylori infection, monitor heart rate and rhythm when administering
medication, report change in bowel pattern to provide, do not crush or chew tablets

Name: polyethylene glycol 3350/Miralax Concentration: Dosage Amount: 17 GM/packet

Route: oral Frequency: 1 packet two times daily

Pharmaceutical class: osmotic laxative Home Hospital or Both
Indication: constipation
Adverse/ Side effects: moderate to severe: nausea, bloating, cramping, gas, diarrhea, or hives

Nursing considerations/ Patient Teaching: Combine with 8 oz. of fluid and stir until dissolved completely, inform patient it may take 2-4 days for the medication
to relieve constipation, encourage patients to maintain adequate fiber and fluid intake, patients may preform moderate exercise to promote gastric motility

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Name: ranitidine/Zantac Concentration: Dosage Amount: 150mg

Route: oral Frequency: 1 tablet at bedtime

Pharmaceutical class: H-2 receptor antagonist Home Hospital or Both
Indication: Reflux
Adverse/ Side effects: headache, constipation, diarrhea, nausea, vomiting, stomach pain
Nursing considerations/ Patient Teaching: Nurse should obtain patient’s history of ulceration, patient should be educated to report any worsening o prolonged
experience of symptoms, patient should increase fluids

Name: spironolactone/Aldactone Concentration: Dosage Amount: 25mg

Route: oral Frequency: 1 tablet daily

Pharmaceutical class: potassium sparing diuretics Home Hospital or Both
Indication: Prevent clot formation
Adverse/ Side effects: postural hypotension, hyponatremia, fatigue, gynecomastia, impotence, amenorrhea, hyperkalemia, blood dycrasias
Nursing considerations/ Patient Teaching: Nurses should obtain electrolyte levels before medication administration, patient should not consume salt
substitutes/potassium supplements/ACE inhibitors, instruct patient to rise slowly to prevent hypotension

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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? Analysis of home diet (Compare to “MyPlate” and
Patient is on a clear liquid, renal diet focused on low consider co-morbidities and cultural considerations):
sodium, potassium, and phosphate.
Based on the analysis of the patients average 24-hour home
Diet patient follows at home? diet, MyPlate recommendations, and renal diet
Patient stated that her sister (caregiver) encourages her to recommendations, there are a few adjustments that may
make decisions conscious of her renal condition. They “try benefit the patient. I would first encourage the patient to
to follow the rules” but sometimes she “wants what she keep a more accurate log of her intake of fluids. When
wants”. questioning about daily intake of fluids, the patient was not
able to report an estimate. Because of her history of fluid
24 HR average home diet: overload, I would recommend that the patient meet with her
Breakfast: Patient stated she likes “to eat eggs on an provider to determine a level of fluid intake that would be
english muffin, with fruits for breakfast”. specific to her needs. Also, I would recommend a closer
monitoring of her sodium intake. Foods such as the english
Lunch: Patient stated that her “sister likes to make her eat a muffin and pasta could potentially have a high level of
lot of salads for lunch” and “sometimes she lets her have sodium. This could exacerbate her renal failure and fluid
chicken on it”. overload. I would suggest a greater emphasis on
management of her protein intake. If she is having eggs for
Dinner: Patient stated her caregiver encourages her to eat breakfast, chicken at lunch, and again at dinner, she could
something “healthy” like “chicken with a tiny bit of pasta”, be consuming a high level of protein. MyPlate indicated
but always asks her to “eat all of her veggies”. Patient that she is nearing the upper level of recommended protein
stated sometimes she is “not hungry” at dinner time. intake. Her renal failure impairs her ability to process
protein, so she could potentially have problems related to
Snacks: Patient stated that she “is not much of a snacker”. her elevated protein level. Overall, I believe the patient
would benefit from a consult with a dietary specialist.
Liquids (include alcohol): Patient stated that all she drinks
is water with occasional fruit juice- perhaps “one glass of
juice once or twice a week”. She stated she does not drink
any caffeinated beverages or alcohol.

Use this link for the nutritional analysis by comparing the

patients 24 HR average home diet to the recommended
portions, and use “MyPlate” as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM:

Who helps you when you are ill?
The patient reported that her sister is the primary individual who assists her when she is not feeling well. Patient states
that she has been living with her for “a while now” so they “have a routine down”. She described that her sister knows
when she needs help and when she is able to do tasks independently. Patient stated she “is very independent” and likes to
do things on her own if she can. She also has several close friends, from childhood and her church, that help her when her
sister cannot.
How do you generally cope with stress? or What do you do when you are upset?
Patient reported she really enjoys playing her trumpet. Music is very important to her because “it takes her mind off of
everything and gives her joy”. She also explained that visits with her nieces and nephews lift her spirits. The patient stated
University of South Florida College of Nursing – Revision September 2014 9
that “without them, she gets really bored and need a distraction”. Family and her music seem to be positive outlets that
allow her to cope with the stress of several chronic illnesses.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reported feeling a bit “unsure of everything” when she was initially admitted to the hospital. This is evidenced by
the behavioral changes noted by the FHT staff and her family. Now, patient reports feeling “fine” because she has “met so
many nice, new people” and her family has been visiting. She is just ready “to go back home and know what is wrong
with her”. Per patient report, patient is not dealing with any difficulty, or lasting emotional changes related to her illness
or other factors, and is communicating with her family and friends.

+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? “Oh, no never.”

Have you ever been talked down to? “Never.” 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? Not applicable

Are you currently in a safe relationship?

“I am not in a romantic relationship, if that is what you mean. However, my family and friends sure do make me feel
safe”. Based on all accounts and experiences with her many visitors, the patient is in safe, loving relationships with her
family and friends. She has been in romantic relationships since her husband died, but patient reported that all were “quite
healthy relationships”.

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s 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 Erickson’s
developmental stage for your patient’s age group:
In this stage of development, the client must come to terms with their life and its worth so they can accept their eventual
death. Ego integrity is characterized by “a satisfaction with life” and “understanding of one’s place” in the world (Treas,
L. S., & Wilkinson, J. M., 2014, p.165). Despair is characterized by “discomfort with life and aging, and a fear of death”
(Treas, L. S., & Wilkinson, J. M., 2014, p.165).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
The patient is in “ego integrity vs. despair” in that the primary struggle for her is to find a larger meaning for her life prior
to her acceptance of death. She has resolved this stage’s conflict by finding “ego integrity”. This is evidenced by the
patient speaking fondly of the time in her life when she was a teacher, and her description of the impact she had on
various students. It is also clear from her frequent visitors that she has healthy, influential relationships with her family
and friends. One account from a friend outlined how much the patient “means to her nieces and nephews” in that they ask
frequently to see her. Another friend stated that everyone at her church has asked about her and is “anxious for her return”
to their usual activities. The patient does not report fear of death and appears to be secure in the “legacy” she will leave
when she passes. Even among staff at FHT, the patient is well liked and will not be forgotten. There is no reported, or
apparent, anxiety in the patient; but rather she is peaceful and a source of strength to those around her. (Sigelman, C. K.,
& Rider, E. A., 2012)

University of South Florida College of Nursing – Revision September 2014 10

Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
Her condition has secured her stability in “ego integrity”. The patient realizes that because of her multiple co-morbidities,
she may not live quite as long as other individuals. This has caused her to examine her life and what it has meant to her.
Also, her condition has caused the patient to be more secure in her religious beliefs. The patient draws significant strength
and peace from her religious beliefs, and this transfers to her acceptance of the “legacy” of her life.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
Patient stated she “didn’t know why she was sick and was hoping the doctors here could figure it out”. After a moment
though, she stated that she didn’t believe in one exact cause but that it was “many things”.
What does your illness mean to you?
Patient stated she was extremely independent prior to her diagnoses of her various conditions. She told many stories of her
travels to Alaska, Europe, and Israel. “Back then”, she described herself as “always zipping around here and there trying
to help her family and friends”. The patient stated her illnesses have meant a decrease in this independence. She stated
that “when they took away her car 14 years ago she was sad for a while because she was so used to doing things for
herself”. This illness has caused the patient to “learn how to accept help”.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with:” I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”

Have you ever been sexually active? “Yes.”

Do you prefer women, men or both genders? “Men.”
Are you aware of ever having a sexually transmitted infection? “No.”
Have you or a partner ever had an abnormal pap smear? “No.”
Have you or your partner received the Gardasil (HPV) vaccination? “No.”

Are you currently sexually active? “No.” If yes, are you in a monogamous relationship? Not applicable

When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an
unintended pregnancy? “When I was younger I used the pill or protection, but I don’t need that anymore.”
How long have you been with your current partner? “I do not have a current partner. It was never the same after my
husband died.”

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 September 2014 11

±1 SPIRITUALITY ASSESSMENT:

What importance does religion or spirituality have in your life?

Patient reported that religion is the “most important thing in her life”. She was raised in her faith and never deviated from
it as she was growing up. She stated that “God keeps her from doing bad things in her life. He gave her family, friends and
made her the person she is today”. The patient went on to describe that “music and Christian TV” is all she does and that
“nothing else matters as much”.
_____________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
“It helps me find peace.” The patient stated that even though her illness can be “scary” at times, she knows that “God will
take care of her and help the doctors”.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
Patient stated she never had any desire to smoke. The “smell was so awful” to her that she reported never being interested
in trying it. Now, she stated she “wouldn’t think of trying because of her conditions”.

If so, what? How much?(specify daily amount) For how many years? X years
(age thru )

If applicable, when did the

Pack Years:
patient quit?

Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit?
so, what, and how much? “No.” If yes, what did they use to try to quit? Not applicable.

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
Patient stated she never drank because her parents wouldn’t have approved when she was younger. Then, as she was
growing up, she never desired a taste “because it was not part of her lifestyle”.

What? How much? For how many years?

Volume: (age thru )
Frequency:
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?
How much? For how many years?
(age thru )
Is the patient currently using these drugs?
If not, when did he/she quit?
Yes No

4. Have you ever, or are you currently exposed to any occupational or environmental hazards/risks?
Patient reported that many years ago, the exact number she was unsure of, she worked in a small office space. She reported
that it was about the size of a large living room. She worked in that space with 3-4 other people. Her coworkers all smoked
frequently. Patient stated that they never smoked in the office itself, but that she would often cough just from the smoke
“lingering on them” every day after their smoke break. Aside from this, she stated that she was not exposed to any
chemicals or hazards.

5. For Veterans: Have you had any kind of service related exposure?
Not applicable.

University of South Florida College of Nursing – Revision September 2014 12

 10 REVIEW OF SYSTEMS NARRATIVE
General Constitution
How do you view your overall health?
“I think I am as healthy as I possibly can be with everything I have going on.”
Integumentary: Patient denies problems with her nails or rashes. She reported that she has noticed an increase
in bruising as she has gotten older. Abrasive contact exacerbates the condition, and it is typically located on her
extremities. The bruising varies in size and shape, and is made better with limited contact and rest. The patient
also reported seldom use of sunscreen throughout her entire life.
HEENT: Difficulty seeing was reported by the patient, and is managed by glasses- patient does not know the
exact prescription. She reports annual vision screenings. Patient reports cataracts, difficulty hearing in her left
ear, and dental problems. She indicated that she does not have regular dental visits. Patient denies frequent ear
infections, sinus infections, pharyngeal infections, or nose bleeds.
Pulmonary: Patient reports frequent episodes of dyspnea, cough, and pneumonia related to diagnosis of
congestive heart failure. Patient also reported a diagnosis of chronic obstructive pulmonary disease, that when
exacerbated, leads to dyspnea and cough. The patients denies a history of asthma, emphysema, tuberculosis, or
environmental allergies.
Cardiovascular: Patient has a history of hypertension, chest pain/angina, coronary artery disease,
hyperlipidemia, and congestive heart failure. The patient has also had an aortic valve replacement, carotid
stenosis with endarterectomy, and a pacemaker inserted. The patient denies rheumatic fever. She is currently on
continuous EKG monitoring.
GI: Patient reports nausea, vomiting, diarrhea, and constipation. The patient reports chronic indigestion and
diverticulitis, relieved with a change in diet. She denies a history of hemorrhoids, jaundice, pancreatitis, colitis,
appendicitis, and hepatitis.
GU: Patient reports a previous history of nocturia, but reports resolved. She reports a history involving a
possible inguinal hernia leading to polyuria, but states resolved. She indicated that she has had urinary tract
infections accompanied by kidney stones. The patient stated she “urinates a few times a day, like the average
person”.
Women/Men Only: The patient reports no history of infection in female genitalia. Patient reported a
hysterectomy, which “set off early menopause”. She reported oligomenorrhea for “several years” after the
procedure, followed by amenorrhea. She “can’t say when she went through menopause because she didn’t go
through it normally”. Patient denies monthly self-breast exams, regular gynecologic visit, pelvic exams, and
does not recall last mammogram.
Musculoskeletal: Patient reports a history of musculoskeletal weakness related to aging. Patient reports a
history of back spasms in the thoracic and lumbar regions, and gout in “almost every part of the body”. Patient
indicated that there is a family history of arthritis, as well. Patient denies fractures.
Immunologic: Patient denies chills with severe shaking, night sweats, unexplained fever, HIV/AIDS, lupus,
rheumatoid arthritis, anaphylaxis, or enlarged lymph nodes.
Hematologic/Oncologic: Patient denies a history of anemia or bleeding easily. She reported bruising easily.
Patient denies history of cancer.
Metabolic/Endocrine: Patient denies a history of diabetes, intolerance to hot/cold, or osteoporosis. She reported
a history of hypothyroidism.
Central Nervous System: Patient denies a history of seizures, tremors, and meningitis. Patient reports a history
of dizziness and migraines. She reported that the migraines have subsided in the last 5 years.
Mental Illness: Patient denies a history of schizophrenia, chronic depression or anxiety, or bipolar disorder.
Childhood Diseases: Patient denies history of mumps, polio, or scarlet fever. Patient reports a history of
measles and chicken pox. Patient also indicated that she had an outbreak of shingles in the last 2 years. It was
located under her breasts and radiated around her back.

University of South Florida College of Nursing – Revision September 2014 13

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.”

±10 PHYSICAL EXAMINATION:

General survey: Patient is a well-developed, 76-year-old who is obese. Patient does not exhibit signs of respiratory distress
or complain of shortness of breath. Patient reports feelings of constipation and pain in the right lower quadrant of her
abdomen. Vitals taken at 0800 on 7/21/16 are listed below.
Height 156 cm Weight 97.6 kg BMI 40.1 Pain 4, RLQ of abdomen
Pulse 65 Blood Pressure 113/56, left upper arm Temperature 97.7 oral
Respirations 20 SpO2 99% Room Air or O2 Room Air
Overall Appearance Patient is clean, with hair combed. Patient is dressed appropriately for the setting and temperature.
Patient maintained eye contact and did not appear to be in/or report distress. There are no obvious handicaps.
Overall Behavior Patient is awake, calm, and relaxed. She responds appropriately for her age and education level.
Judgement and decision making skills appear to be intact. Patient did become drowsy during the patient interview, but
reports feeling tired secondary to her dialysis treatment.
Speech Patient responds in appropriate amount of time with clear and concise speech. There is no abnormal slurring or long
periods of silence. Patient does not report difficulty speaking or understanding speech.
Mood and Affect Patient is pleasant, cooperative, cheerful, and talkative.
Integumentary Skin is warm, and dry. It appears to be pale and there is evidence of ecchymosis on the upper and lower
extremities. Skin turgor is elastic and capillary refill is brisk and under three seconds.
IV Access Patient has 22-gauge IV in the right AC and a central venous catheter in the right subclavian area. There is no
erythema, heat, or discharge surrounding the points of insertion.
HEENT Facial symmetry is intact. PEERLA intact. Ears and nose without lesions or discharge. Mucosa is pink, moist, and
without lesions.
Pulmonary/Thorax Patient’s airway is patent, and respirations are regular without report of dyspnea. All lobes diminished
with no mucus production reported. Patient is on room air and there is no increased work of breathing.
Cardiovascular S1 and S2 heard, regular rate and rhythm, no extra sounds auscultated. Mild to moderate non-pitting
edema is noted in the lower extremities. Radial pulses 2+, equal bilaterally. Pedal pulse 1+, mildly diminished bilaterally.
GI Abdomen is firm in the lower quadrants, soft in the upper quadrants. Normoactive bowel sounds and no bruits
auscultated. Tenderness reported in the right lower quadrant upon palpation, no masses noted. Patient is continent, but
reports feelings of constipation, and is experiencing diarrhea. Denies nausea and vomiting.
GU Patient uses either the bedside commode or regular bathroom, with assistance ambulating to both. Patient is continent
and reports no difficulty voiding. No catheter is present.
Musculoskeletal Patient has weakness in all extremities, 4/5 bilaterally. Pedal pulses diminished. No report of numbness or
tingling.
Neurological Patient is alert and oriented, to person, place, and time. Sensation is intact to light touch and pressure.

±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS:

Lab Dates Trend Analysis

Troponin T (normal < Troponins were high Patient is admitted for
0.01) upon admission. These exacerbation of CHF and
0.04 H 06/21/2016 levels were drawn at has a history of cardiac
admission to establish a dysfunction. The elevated
University of South Florida College of Nursing – Revision September 2014 14
 baseline. troponin is indicative of
her current acute cardiac
state as well as her
previous history.
proBNP (normal < 300) PropBNP level was high The patient has CHF
H 2586 06/21/20/16 upon admission. This failure so an elevated
level was drawn at proBNP indicates the
admission to gather an fluid overload associated
understanding of the level with the disease process.
of CHF exacerbation. Per patient, this level is
“actually lower than it
normally is”.
WBC (normal 4.5-11) WBC levels were normal The patient started
7.9 06/21/2016 upon admission, but dialysis on 06/28/2016,
trended upward slightly. and as a result the skin is
12.8 H 07/11/2016 no longer intact. This
predisposes her to
infection. However, the
level is only slightly
elevated, and there is no
other sign of infection.
Hemoglobin (normal Upon admission, Patient was admitted with
12-16) 06/21/2016 hemoglobin levels were report of “difficulty
11.3 L slightly low, but breathing”. Hemoglobin
07/11/2016 improved throughout her is indicative of oxygen
13.0 hospital stay. saturation. Low
hemoglobin could
correspond with an
increased work of
breathing, which was
relieved with BiPAP and
albuterol treatment.
Hematocrit (normal 36- Hematocrit was within Hematocrit was stable
47) normal range throughout throughout the hospital
36.9 06/21/2016 her hospital stay. stay which corresponds
with her absence of blood
39.3 07/11/2016 disorders.
Platelet (normal 150- Platelet count was within The patient is taking
450) normal ranges. It was on antiplatelet medications,
173 06/21/2016 the “lower side” of so it is appropriate that
normal. her levels are “low
157 07/11/2016 normal”. Also, the patient
has an increased level of
compliance while in the
hospital, so it is
appropriate that her levels
lowered during her stay.

University of South Florida College of Nursing – Revision September 2014 15

Sodium (normal 135- Sodium was “high Patient has renal failure
145) normal” upon admission so a high level of sodium
142 06/21/2016 and trended down to a is expected as her
low level throughout the excretion is impaired. She
131 L 07/11/2016 stay. was started on dialysis
and is adhering to diuretic
128 L 07/12/2016 therapy while in the
hospital, so renal function
is improving. This
corresponds with her
lowering levels of
sodium.
Potassium (normal 3.5- Potassium was high upon The patient has impaired
5) admission, and trended renal function and is
H 5.2 06/21/2016 down to a low level, and taking a potassium
then back to within sparing diuretic at home.
L 2.9 07/11/2016 therapeutic range. This may have
contributed to her initial
3.9 07/12/2016 high level. The trend
downward corresponds to
her improved renal
function related to
dialysis.
Chloride (normal 95- The chloride level was Typically, chloride and
105) within normal range upon sodium levels correlate. It
102 06/21/2016 admission. The levels is expected for this
trended downward patient to have a lower
89 L 07/11/2016 throughout the stay. chloride level as they had
a lower sodium level
89 L 07/12/2016 related to diuretics and
dialysis.
CO2 (normal 23-39) CO2 levels were within Low CO2 can be related
27 06/21/2016 normal range upon to pathology such renal
admission, and trended dysfunction or an acute
18 L 07/11/2016 down to a consistent low condition such as
level. diarrhea. The patient was
18 L 07/12/2016 experiencing both as her
levels started to decrease.
Glucose (normal 70- Glucose was high upon The patient is not
100) admission, and fluctuated diagnosed with diabetes;
104 H 06/21/2016 throughout her stay. It however, she does have a
remains in the high family history of
98 07/11/2016 normal range, and did diabetes. It is likely that
increase to above normal she has a genetic
103 H 07/12/2016 on occasion. predisposition to
impaired regulation of
glucose, even if it is not
classifiable as diabetes.

University of South Florida College of Nursing – Revision September 2014 16

 BUN (normal 7-20) The patient’s BUN was The history of renal
100 H 06/21/2016 high upon admission, and impairment is responsible
remained so throughout for the elevated BUN.
62 H 07/11/2016 the stay. It is trending The levels have started to
downward, but remains decrease as a result of
74 H 07/12/2016 higher than normal. dialysis intervention.
Creatinine (normal 0.6 Creatinine was high upon Creatinine is a byproduct
to 1.1) admission, and trended of muscle breakdown.
2.3 H 06/21/2016 upwards throughout her The patient ambulates
stay. only a few times a day,
6.4 H 07/11/2016 and only in short
distances. Her activity
7.6 H 07/12/2016 intolerance could
potentiate muscle
breakdown. Also, with
severe renal failure (i.e.
stage IV), dialysis may
not resolve a high
creatinine level.

06/22/16 US Ext Lower Venous Duplex Bil: indicated for edema, pain, rubor
Impression: no evidence of DVT

06/23/2016 XR Chest 2V: indicated for patient report chest pain/pressure

Impression: no evidence of pneumothorax or pleural effusion

07/02/2016 CT Head/Brain WO Contrast: indicated for acute mental status change

Impression: no brain anomalies aside from age related cerebral atrophy

07/09/2016 XR Abdomen Flat/Upright W Chest 1V: indicated to rule out bowel obstruction per patient report
of “feelings of constipation”
Impression: possible obstruction at level of sigmoid colon, gas in non-distended small bowel

07/10/2016 CT Abdomen W/O & Pelvis W/O Contrast: indicated per increased abdominal pain distal to
location of suspected obstruction
Impression: partial large bowel obstruction that is associated with the band placed in hysterectomy; trace
right pleural effusion

07/10/2016 XR Barium Enema W Gastrografin: indicated for sigmoid obstruction

Impression: fixed narrowing of the bowel which could “certainly contribute to the large bowel obstruction
distal”

07/11/2016 XR Abdomen Flat/Upright: indicated for colonic distention

Impression: air distention of the colon- particularly descending and transverse

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:

Vital signs- per unit routine.
Activity as tolerated, but with assistance after dialysis- Assistance is indicated per patient reports of feeling weak
University of South Florida College of Nursing – Revision September 2014 17
or dizzy.
Diet- clear liquid, renal diet (low Na, K, phosphate). The patient is on clear liquids until the feeling of
constipation is resolved. A low sodium diet will help maintain an appropriate blood pressure, fluid volume, and
renal function. The patient must be on a renal diet as the dysfunction prevents her from appropriately filtering
nutrients.
BiPAP and consult with respiratory therapist as needed per patient report of dyspnea- Patient has a history of
sleep apnea, so the BiPAP machine was brought from home, after provider’s approval, for use when needed.
Patient experienced intermittent dyspnea related to fluid overload since her admission, so consult with respiratory
therapist is utilized when needed.
Physical therapy consulted to promote patient ambulation- Ambulation will promote patient autonomy and
adequate circulation in her lower extremities. They are also working with the patient in coping with the dizziness
and weakness she has reported after dialysis on occasion.
Dialysis 3 times a week for renal failure and fluid overload.
Nephrology consulted for management of renal failure on 06/21/2016- Education on dialysis and proper diet was
provided to patient and caregiver.

 8 NURSING DIAGNOSES

1. Excess fluid volume related to impaired excretion of sodium and water as evidenced by edema in extremities,
mildly diminished pedal pulses, and elevated proBNP.

2. Activity intolerance related to weakness/fatigue as evidenced by verbal report and exertional

discomfort/dyspnea, increased when following dialysis.

3. Constipation related to activity intolerance as evidenced by radiology revealing obstruction, change in bowel
pattern, and liquid/loose stools.

University of South Florida College of Nursing – Revision September 2014 18

± 15 CARE PLAN
Excess fluid volume related to impaired excretion of sodium and water as evidenced by edema in peripheral pulses, diminished pedal pulses, and
Patient Goals/Outcomes
Client will not experience an
increase in edema during current
shift, and experience a decrease in
edema by end of week.
Nursing Diagnosis:
elevated proBNP.
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Administer prescribed diuretics as Diuretics encourage renal excretion Diuretics were given at correct
needed, assessing blood pressure of sodium which increases fluid times, when indicated per
before administration to ensure it is excretion, lowering the fluid provider’s orders. No adverse
indicated. volume that is in excess. reactions reported/noted.

Transport patient to dialysis at Dialysis removes sodium and Patient to dialysis at 0800 and
appropriate time, checking vital excess fluid in patients with return 1230. Patient tolerated the
signs prior to transfer to ensure it is impaired renal function. procedure well, and reported
appropriate. “feeling better” upon return.

Client will not experience
worsening lung sounds during
current shift, and will improve by
end of week.
Monitor location and severity of
edema, using the 1+ to 4+ scale to
grade edema, noting any
differences in measurement
throughout shift.
Auscultate lung sounds for
crackles, monitor respirations for
change in quality/level of exertion.
The presence and severity of
edema is indicative of the extent of
fluid overload.
Crackles, or other adventitious
sounds, can be indicative of fluid in
the lungs. This can occur
secondary to the fluid overload
from CHF and renal failure.
Edema noted as mild to moderate
(1+) at beginning of shift. At end
of shift, there was no worsening of
the edema.
Lungs sounds auscultated as
diminished at beginning of shift,
and this was consistent throughout
the day and at end of shift. There
was no worsening in condition or
report of dyspnea.

Consult respiratory therapy if Referring to qualified Patient did not report dyspnea, so
patient reports increased work of interdisciplinary team members respiratory therapy was not
breathing or abnormal sounds provides patient centered care. Per indicated.
auscultated. provider’s orders, respiratory
therapists can administer breathing
treatments
University of South Florida College of Nursing – Revision September 2014 19
Client will explain actions needed *Provide patient with educational If the patient understands why they Patient reports understanding of
to manage symptoms of fluid materials regarding purpose of are taking a medication, there will why she is taking her medications.
excess relating to medication medications. be a higher rate of compliance. She is able to recall information
regimen and diet by end of shift. upon questioning.

*Teach patient appropriate
schedule of medication
administration when at home.
The patient will experience less
side effects from the medication,
such as nocturia if they took a
diuretic in the evening.
Patient reports understanding of
proposed schedule, but remains
insistent that her caregiver can
“handle all of that for her”. In the
future, a greater emphasis on
developing autonomy will be place.

*Reinforce purpose of adherence to In individuals with renal Again, patient reports

renal diet, both in the hospital and dysfunction, it is critical that they understanding of education, but
at home. maintain a diet with low levels of that caregiver is “responsible for
Na, K, etc. as their kidneys cannot her diet choices”. Again, I wound
adequately filter the nutrients. emphasis the importance of
autonomy.
Nursing diagnoses and care plan reference: (Ackley, B. J., & Ladwig, G. B., 2014)

±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:
▪ The patient and caregiver would benefit from a reinforcement of food choices that adhere to the renal diet.
* PT/ OT:
▪ The patient has a decrease in mobility related to the fatigue from dialysis treatment and dyspnea from her chronic health conditions. The
patient would benefit from teaching regarding how to cope with these problems when preforming her activities of daily living (ADLs).
□Pastoral Care
□Durable Medical Needs
* F/U appointments:
▪ It is critical that the patient has appropriate follow up appointments to manage her conditions, monitor adherence to her pharmacologic
regimen, and monitor effectiveness of dialysis treatment. The patient will also be able to present any concerns they have to the provider.
* Med Instruction/Prescription
▪ Are any of the patient’s medications available at a discount pharmacy? *Yes □ No
University of South Florida College of Nursing – Revision September 2014 20
 ▪ The patient and the caregiver have an adequate understanding of the purpose of her medications, as well as the appropriate administration
schedule. However, it should always be reinforced periodically to maintain adherence.
□Rehab/ HH
□Palliative Care

University of South Florida College of Nursing – Revision September 2014 21

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to

planning care (10th edition ed.). Maryland Heights, MO: Mosby/Elsevier.

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th edition ed.). St.

Louis, MO: Mosby/Elsevier.

Karch, A. M. (2016). Lippincott's pocket drug guide for nurses (2016 ed.). Philadelphia, PA:

Wolters Kluwer.

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2015). Pharmacology: A patient-centered nursing

process approach (8th ed.). St. Louis, MO: Elsevier.

Sigelman, C. K., & Rider, E. A. (2012). Life-span human development (7th edition ed.). Belmont,

CA: Wadsworth.

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills, & reasoning.

Philadelphia, PA: F.A. Davis Company.

University of South Florida College of Nursing – Revision September 2014 22