Professional Documents
Culture Documents
COLLEGE OF NURSING
1 CHIEF COMPLAINT:
“Chest pain, weakness, passing out”
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient reports feelings of “weakness” and “chest pain” and says he feels like “passing out”. These symptoms started
around ten days ago. Reports that his chest pain is “sharp/stabbing” and comes in “short spurts”. Reports unusual
feeling of bounding heart beat and discomfort in his chest. Before admission, patient was driving when he suddenly felt
dizzy and “out of it”. He reportedly went through a red light as a result of this. Upon urging from his wife, he brought
himself into the emergency room. EKG shows sinus rhythm with occasional atrial fibrillation and premature ventricular
contractions. Suspects some sort of problem from his beta-blocker. His beta-blocker dose was decreased upon
admission and he is being monitored for any effects of this medication adjustment.
2
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 84 N/A
Mother 85 N/A
Brother 59 N/A
Sister 61 N/A
Sister 58 N/A
Sister 57 N/A
N/A
1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service N/A
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? 2014
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received
NKDA
Medications
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)
With a primary diagnosis of chronic atrial fibrillation, this patient experienced irregular heartbeats resulting from
abnormal electrical impulses. The electrical activity behind atrial fibrillation is rapid and begins in an area other than the
SA node. Most often the impulse starts in the pulmonary veins (Markides and Schilling 2003). Common causes of atrial
fibrillation are thought to be abnormal heart structure, ischemic events, hypertension, and even genetics (Markides and
Schilling 2003). Because of the rapid contractions of the atria, ventricular rhythm also increases so blood is not pumped
effectively as the chambers are unable to completely fill. Diagnosis of this diseases is made by electrocardiogram
confirmation. Treatment is geared towards regulating abnormal heart rhythm. Medications used in atrial fibrillation
management include anti-hypertensives, like the patient’s prescription of atenolol. Beta-blockers are one example of how
to slow impulses traveling to the ventricles (Beers 2003). Although medication can be used to manage and control atrial
fibrillation, if normal rhythm cannot be achieved or maintained a cardiac ablation can interrupt conduction. A cardiac
ablation is a procedure in which radiofrequency energy is applied to the heart through a catheter (Beers 2003). This
patient underwent three of these procedures.
5 MEDICATIONS: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if
given in last 48°). Give trade and generic name.]
Name atenolol (Tenormin) Concentration 25 mg/ tablet Dosage Amount 12.5 mg (0.5 tablet)
Route PO Frequency- Once daily
Pharmaceutical class Beta Blocker Home Hospital or Both
Indication – used to treat HTN and angina pectoris
Adverse/ Side effects – bradycardia, hypotension, fatigue, dizziness, nausea/vomiting
Nursing considerations/ Patient Teaching – nurses must monitor patient’s BP / teach patient not to discontinue medication
abruptly as rebound HTN, MI, angina, and ventricular arrhythmias may occur, teach patient to take his pulse to
monitor for bradycardia
Name nitroglycerin (Nitrostat) Concentration 0.4 mg/ tablet Dosage Amount 0.4 mg
Route SL Frequency PRN
Pharmaceutical class Nitrate Home Hospital or Both
Indication – treat/prevent angina, lower oxygen demand of heart, prevent MI, standing order for pts on telemetry
Adverse/ Side effects – HA, dizziness, orthostatic hypotension, tachycardia, flushing, palpitations
Nursing considerations/ Patient Teaching – teach patient how to take sublingually, teach patient to seek medical help
immediately if chest pain doesn’t improve or end
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
Wife
How do you generally cope with stress? or What do you do when you are upset?
Walks dogs or talks to wife
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No
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 been talked down to? __No___________ Have you ever been hit punched or slapped? _No__________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______No_________________________________ If yes, have you sought help for this? ___N/A_________________
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:
Generativity is best defined as involvement with one’s life and the people in it, while stagnation is the process of
becoming stagnant or unmoving. (Merriam Webster’s, 2003)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
He is fifty-five years old which would put him in the stage of generativity versus stagnation. Beyond just his age, he fits
into this category based on the way he spoke of his stepson and step-grandchildren. He has an active role as a parent
despite never having biological children and continues that role through his grandchildren. His actions best fit in the
generativity stage as he is involved in their lives and includes them in his. Stagnation would not be an accurate description
of his stage in life because he is not self-absorbed
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
His disease impacts this developmental stage of his life because of his impaired physical abilities. Obviously
hospitalizations impact his time with his family. This also might affect his role as a provider as his illness prevents him
from working. Despite all of this, the patient seems to be content with his current stage of life and had nothing negative to
say about it. He seems secure in his position as a step-parent, step-grandfather, and provider and does not seem to be set
back by his diagnosis.
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
God’s will, genetics
+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”
Are you currently sexually active? ______Yes__________________ If yes, are you in a monogamous relationship?
________Yes________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? ___Condoms_______________________________
How long have you been with your current partner? ______11 years___________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? ____Yes – back pain ___________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? “A lot” For how many years? 32 years
Beer, liquor Volume: N/A (age 18 thru 50 )
Frequency: Everyday
If applicable, when did the patient quit?
5 years ago – 2011 – 50 y.o.
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Marijuana, cocaine How much? For how many years? 1980’s
“A lot” (age 18 thru 30 )
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No – project manager doesn’t have to wear hardhat or be exposed to dangerous equipment
5. For Veterans: Have you had any kind of service related exposure?
N/A
How do you view your overall health? “Pretty healthy, working on it”
Integumentary: Reports no problems with skin. Uses sunscreen when out in the sun, showers every day.
Denies lesions/sores.
HEENT: Reports blurry vision which he wears prescription contacts for all the time. Last eye exam 2015.
Schedules regular dentist appts every 6 months. Reports no changes in hearing.
Pulmonary: Denies difficulty breathing/chest pain. Unproductive cough occasionally. Pneumonia as a child in
the 1970’s.
Cardiovascular: Occasional chest pain, takes daily Aspirin as a “blood thinner”. High blood pressure runs in
his family but patient has never been diagnosed; is currently taking beta-blocker. Has had several surgeries to
fix his atrial flutter.
GI: BM every day, normal, “cast iron stomach”. Denies nausea/vomiting. Denies indigestion.
GU: Denies difficulty voiding. Reports no issues.
Women/Men Only: Reports no concerns. He plans on going in for a prostate exam soon.
Musculoskeletal: No numbness or tingling, no weakness. Suffers from chronic back pain. Had several surgeries
to relieve pain with no success. Opioid pain medicine used to treat pain for years but it made him feel “lousy” so
he stopped. Reports that he lives with the pain in his own way and is not looking for any treatment.
Immunologic: Reports only a minor skin allergy to tape, discovered on past hospital stay.
Hematologic/Oncologic: Denies any problems. Takes Aspirin daily to “thin the blood”.
Metabolic/Endocrine: Denies any problems.
Central Nervous System: Reports occasional headaches. Denies dizziness.
Mental Illness: Denies any mental health problems.
Childhood Diseases: Chickenpox at 8 years old. Pneumonia at 9 years old. Measles at 11 years old.
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 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):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
-Medication adjustment – monitoring effect of lowered beta-blocker dose, taking vitals Q12, B/P Q6
-Random accucheck upon admission – glucose level of 100
-Telemetry monitoring – continuously, patient has hx of atrial fibrillation and was admitted with chest pain
-Regular activity order – independent, no assistance necessary
-Regular diet order
2.
Risk for CVD r/ poor diet, obesity, family hx of HTN, chronic afib
Nursing Diagnosis: Risk for CVD r/t poor diet, obesity, family hx of HTN, chronic afib
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Will decrease cholesterol intake Help client order meals. Teach Cholesterol contributes to Patient will replace saturated fats
to <300 mg a day during hospital about healthy alternatives to atherosclerosis, or the build-up of with unsaturated oils. Will
stay. saturated fats. Provide information plaque in the cardiovascular system supplement current diet choices
about U.S. Dietary Guidelines. (Ackley and Ladwig 2014) with low-fat replacements.
2. Will increase fiber intake to at Teach client benefits of an High-fiber foods help decrease Will consume over 38 grams of
least 38 grams daily. increased fiber intake. Suggest LDL cholesterol and improve fiber. Monitor meal orders. Patient
food such as beans, whole grains, digestion (Ackley and Ladwig will teach back benefits of fiber.
and fruits. 2014)
3. Will increase daily exercise to at Assist client in planning ways to Reduces body weight and risk for Evaluate weight loss, patient
least 30 minutes a day during incorporate activity into his daily CVD. Increases circulation compliance, and testimony.
hospitalization and after discharge. schedule. Suggest step tracker or (Ackley and Ladwig 2014)
discuss gym membership.
University of South Florida College of Nursing – Revision September 2014 12
±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
□Med Instruction/Prescription
□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
Beers, M. H. (2003). The Merck manual of medical information. Whitehouse Station, NJ: Merck &. Co.
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, Mo:
Elsevier.
Markides, V., & Schilling, R. J. (2003, August). Atrial fibrillation: Classification, pathophysiology, mechanisms and drug treatment. Retrieved July
SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved July 26, 2016, from https://supertracker.usda.gov/