UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jennifer R. Carter
Assignment Date: 3/ 3/17
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION Agency:
Patient Initials: DAG Age: 65 Admission Date: 2/15/17
Gender: M Marital Status: Single Primary Medical Diagnosis: Non- ST Elevation
Myocardial Infarction
Primary Language: English
Level of Education: Ninth Grade Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired restaurant owner Elevated troponin, Acute Coronary Syndrome
Number/ages children/siblings: No children. Two sisters, two
brothers. Ages unknown

Served/Veteran: Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: lives alone in a house Advanced Directives: No
If no, do they want to fill them out?
Surgery Date: 2/15/17 Procedure:
Coronary Angioplasty with stent
Culture/ Ethnicity /Nationality: Caucasian
Religion: Agnosticism Type of Insurance: Medicare

1 CHIEF COMPLAINT: chest pain after playing soccer

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
The patient is a 65 year old male with past medical history of depression and anxiety. The patient presented to TGH per
request of primary care physician due to elevated troponin after a report of chest pain. Patient had episode of chest
tightness/pain on Sunday while playing soccer for four hours. The patient described the pain as left-sided and squeezing.
The pain started while playing soccer and lasted for two to three hours, but patient thought it was due to a few collisions
he had during the game with other players. He took 325 mg aspirin twice and ibuprofen four times after the game, rested
for three hours and reported feeling better. He has never had chest pain before and plays soccer every Sunday. He has
never seen a cardiologist and has had no prior heart catheterizations. The patient reports being chest pain free since
Tuesday. He currently has no complaints. Troponin was elevated to 5.6 and ECG resulted with no significant ST
elevations or depressions.

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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
No pertinent past surgical history
2014 Hepatitis C
Age (in years)

Kidney Problems
Environmental

Trouble

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Cause

etc.)
FAMILY
Alcoholism

Glaucoma
Diabetes
Arthritis

Seizures
Anemia

Asthma

of
Cancer

Tumor
Problems

Stroke
Allergies

MI, DVT
Gout
MEDICAL Death

Mental
Heart
HISTORY (if

(angina,
applicable
)
Father 95 Dementia X
Mother 92 N/A X X
50
Brother N/A X X
s
50
Sister N/A X X
s
relationship

relationship

relationship

Comments: Include age of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations X
Routine adult vaccinations for military or federal service X
Adult Diphtheria (Date) X
Adult Tetanus (Date) Is within 10 years? X
Influenza (flu)(11/2/16) X
Pneumococcal (pneumonia) (2/17/17) X
Have you had any other vaccines given for international travel or
occupational purposes? Please List X
If yes: give date, can state U for the patient not knowing date received
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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS
NKDA

Medications

NKA
Other (food, tape,
latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Non-ST Elevation Myocardial Infarction (NSTEMI) is a diagnosis that falls under the umbrella of Acute Coronary
Syndrome (ACS). NSTEMI indicates that myocardial apoptosis has occurred as a result of prolonged muscle ischemia
(Osborn, Wraa, Watson, & Holleran, 2014). Further, apoptosis results in an irreversible loss of cardiac muscle function
(Osborn, Wraa, Watson, & Holleran, 2014). This ischemia resulting in apoptosis occurs from occlusion of a coronary
artery, thus resulting in reduced blood flow. Reduced blood flow occurs as a consequence of plaque accumulating in the
coronary artery. NSTEMI and ACS can be diagnosed using cardiac catheterization, coronary angiography, the presence of
blood serum markers, such as Troponin, and ECG changes (Osborn, Wraa, Watson, & Holleran, 2014). Lastly, NSTEMI
can be treated using the mnemonic device, MONA, which advises patients to use aspirin, supplemental oxygen, morphine,
and nitroglycerin. In addition to MONA, patients experiencing NSTEMI will need to be educated on limiting activity that
requires sudden exertion, the need for a beta-Adrenergic blocking agent, and possible Percutaneous Coronary Intervention
(Osborn, Wraa, Watson, & Holleran, 2014).

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name hydralazine (Apresoline) Concentration Dosage Amount 25 mg

Route PO Frequency every six hours PRN for systolic greater than 170
Pharmaceutical class antihypertensive vasodilator Home Hospital or Both
Indication moderate to severe hypertension
Adverse/ Side effects: Tachycardia, dizziness, drowsiness, arrhythmias, hypotension
Nursing considerations/ Patient Teaching: Monitor BP and pulse frequently, emphasize the importance of continuing to take medication even if feeling well, take at the
same time each day preferably at bed time, Comply with additional hypertension interventions, assess for fluid retention.

Name Aspirin Concentration Dosage Amount 81 mg

Route PO Frequency: Once daily

Pharmaceutical class: nonopioid analgesic Home Hospital or Both
Indication: Decrease incidence of MI, decrease platelet aggregation (necessary for PCI)
Adverse/ Side effects: bleeding, dyspepsia, epigastric distress, nausea, anemia
Nursing considerations/ Patient Teaching: administer with food or large amounts of water/ milk to minimize GI irritation, advise pt to report unusual bleeding
of gums, bruising, black, tarry stools, advise pt to avoid concurrent use of alcohol with this medication to avoid gastric irritation, advise pt to inform health
providers of lng term therapy (may need to be held a week before surgery).

Name: atorvastatin (Lipitor) Concentration Dosage Amount: 80 mg

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Route: PO Frequency: Nightly
Pharmaceutical class: HMG-CoA reductase inhibitor Home Hospital or Both
Indication: primary prevention of coronary heart disease (MI, stroke, angina) in asymptomatic patients
Adverse/ Side effects: abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, rhabdomyolysis
Nursing considerations/ Patient Teaching: advise pt to avoid grapefruit juice to reduce risk of toxicity, advise pt that this medication should be used in
conjunction with dietary restriction on fat, cholesterol, alcohol, and carbohydrates, notify care provider if pt notices unexplained muscle pain, tenderness or
weakness, advise pt to take as prescribed

Name: atropine Concentration: 1 mg/ml Dosage Amount: 0.5 mg

Route: IV Frequency: PRN for bradycardia

Pharmaceutical class: anticholinergic/ antiarrhythmic Home Hospital or Both
Indication: treatment of sinus bradycardia
Adverse/ Side effects: drowsiness, blurred vision, tachycardia, dry mouth, urinary hesitancy
Nursing considerations/ Patient Teaching: assess vital signs and ECG tracings frequently, report any HR and BP changes, monitor I&O due to urinary retention,
advise pt to be cautious with activities that require alertness.

Name: clopidrogel (Plavix) Concentration Dosage Amount: 75 mg

Route: platelet aggregation inhibitor Frequency: Daily

Pharmaceutical class: PO Home Hospital or Both
Indication: reduction of atherosclerotic events in patients at risk of such events including recent MI, ACS, stroke, or PVD
Adverse/ Side effects: GI bleeding, Steven- Johnson Syndrome, Toxic Epidermal Necrolysis, Thrombocytopenic Purpura,
Nursing considerations/ Patient Teaching: Teach pt to temporarily discontinue 5-7 days before surgery, advise pt to take directly as prescribed, advise healthcare
provider promptly if fever, weakness, chills, sore throat, rash, unusual bleeding or bruising, yellowing of skin or eyes, or neurological changes occur.

Name: metoprolol tartare (Lopressor) Concentration Dosage Amount: 12.5 mg

Route: PO Frequency: Twice daily

Pharmaceutical class: beta blocker Home Hospital or Both
Indication: Hypertension, prevention of MI
Adverse/ Side effects: fatigue, weakness, erectile dysfunction, bradycardia, pulmonary edema, anxiety, drowsiness, heart failure
Nursing considerations/ Patient Teaching: monitor HR, ECG, BP frequently, monitor I&O and daily weights along with other signs of heart failure and fluid
retention, advise patient to change positions slowly to minimize orthostatic hypotension, caution pt that medication may cause drowsiness, instruct pt to take
dose as prescribed

Name: clonazepam (Klonopin) Concentration Dosage Amount: 0.5 mg

Route: PO Frequency: twice daily PRN for anxiety

Pharmaceutical class: benzodiazepine Home Hospital or Both
Indication: decrease manifestations of panic disorder
Adverse/ Side effects: behavioral changes, drowsiness, ataxia, suicidal thoughts
Nursing considerations/ Patient Teaching: advise pt to take medication as directed, advise pt that clonazepam is short term, inform pt that the medication may
cause drowsiness and to use caution, assess need for continued treatment regularly, monitor for behavioral changes that could indicate emergence or worsening
suicidal thoughts

Name: sertraline (Zoloft) Concentration Dosage Amount: 100 mg

Route: PO Frequency: Twice daily

Pharmaceutical class: selective serotonin reuptake inhibitors Home Hospital or Both
Indication: decrease major depressive disorder
Adverse/ Side effects: dizziness, drowsiness, fatigue, headache, insomnia, diarrhea, dry mouth, nausea, sexual dysfunction, increased sweating, tremor, serotonin
syndrome
Nursing considerations/ Patient Teaching: assess for suicidal tendencies, especially during early therapy, monitor appetite and nutritional intake, instruct pt to
take medication as directed, inform pt that the medication may cause drowsiness and to use caution, advise pt to avoid alcohol or other CNS depressant drugs

Name Concentration Dosage Amount

Route Frequency

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Pharmaceutical class Home Hospital or Both
Indication
Adverse/ Side effects
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? MCLS Heart Healthy Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Consider co-morbidities and cultural considerations):
24 HR average home diet: This patients home diet appears to be very heavy and
composed mainly of saturated fats, sugars, and sodium.
However, this is exactly the diet that MyPlate advises
individuals to avoid. Willet (2012) recommends replacing
saturated fats and carbohydrates with a combination of
poly- and mono- unsaturated fats. Further, this patient
should be advised to reduce and replace intake of red meats
and dairy products with nuts, fish, such as Salmon, soy
products and nonhydrogenated vegetable oils (Willet,
2012). Implementing these dietary changes is said to have
a beneficial effect on ceasing the progression of Acute
Coronary Syndrome because it improves the combination
of fatty acids.
Breakfast: pancakes, or French toast, bacon, eggs

Lunch: ham sandwich, chips, cookie

Dinner: chicken/shrimp pasta, bread, salad

Snacks: none

Liquids (include alcohol): pepsi, orange juice, beer, straight

liquor beverages

Use this link for the nutritional analysis by comparing the

patients 24 HR average home diet to the recommended portions,
and use My Plate as a reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?

Family members. I was born here so I have a lot of family nearby that are willing to help.

How do you generally cope with stress? or What do you do when you are upset?

Well I used to drink ad take drugs, but 15 years ago I said I had enough. Now, I tend to live in the moment, not worrying
about the past or present.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)

No, Im ok. Sometimes I get suicidal thought, but not recently.

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+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.

Have you ever felt unsafe in a close relationship? No

Have you ever been talked down to? No Have you ever been hit punched or slapped? No

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? NO
If yes, have you sought help for this? ________________

Are you currently in a safe relationship? YES

4 DEVELOPMENTAL CONSIDERATIONS:
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. X 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:

Per Halter (2014), self absorption/ stagnation is defined as the inability to grow as a person. Alternatively, generativity is indicated as
the ability to care for and give to others.

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

This patient appears to be in the self-absorption/ stagnation stage because he appears to be self-centered and unconcerned with
improving his current condition in attempt to be better and serve as an example for others. For instance, when he was asked about his
family dynamics and their ages, he stated that he does not keep up with them enough to know their exact ages. However, he believes
that if he falls too sick to take care of his self that his siblings and other family members will stop everything to take care of him.
Additionally, the patient indulges in risky health behaviors that potentially can endanger his current health status and further displays a
stage of self-absorption. These behaviors include, but are not limited to, indulging in unprotected sexual activities, concurrent alcohol
and medication use, and isolation.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

The patient denies being impacted by his current condition and hospitalization. However, upon assessment, the patient exhibited signs
of anxiety and difficulty adjusting to new healthcare regimens and necessary lifestyles changes.

What do you think is the cause of your illness?

I dont really have any idea. Thats too much of a medical question. I dont do anything right: eat, drugs, alcohol. I
dont know.
What does your illness mean to you?

I dodged a bullet. I need to do better. I shouldve made better choices.

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

Have you ever been sexually active? Yes

Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
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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? Hardly

If yes, are you in a monogamous relationship? Yes
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? None

How long have you been with your current partner? Seven years

Have any medical or surgical conditions changed your ability to have sexual activity? No

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
NO

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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?

Spirituality doesnt mean anything to me. I dont really think about it often or ever
_________________________________________________________________________________________________
Do your religious beliefs influence your current condition?

Not at all.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
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 patients 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?

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
How much? A few glasses or beers
What? Liquor, beer For how many years?
bottles
Volume: 25 grams (age 20 thru 50 )
Frequency: every night
If applicable, when did the patient quit? 15
years ago

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
How much?
Per patient: too much to
Cocaine, marijuana, heroin calculate. A few lines of For how many years?
cocaine a day, a few blunts a
day. I didnt really like heroin.
(age 20 thru 50 )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
5 years ago

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

5. For Veterans: Have you had any kind of service related exposure? NO

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 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Integumentary Constipation Irritable Bowel Night sweats
Changes in appearance of skin GERD Cholecystitis Fever
Problems with nails Indigestion Gastritis / Ulcers HIV or AIDS
Dandruff Hemorrhoids Blood in the stool Lupus
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
Use of sunscreen SPF: Diverticulitis Life threatening allergic reaction
Bathing routine: Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area Last colonoscopy?
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia Bleeds easily
Difficulty hearing dysuria Bruises easily
Ear infections hematuria Cancer
Sinus pain or infections polyuria Blood Transfusions
Nose bleeds kidney stones Blood type if known:
Post-nasal drip Normal frequency of urination: x/day Other:
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
Routine brushing of teeth x/day Diabetes Type:
Routine dentist visits x/year Hypothyroid /Hyperthyroid
Vision screening Intolerance to hot or cold
Other: Osteoporosis
Other:
Pulmonary
Difficulty Breathing Central Nervous System
Cough - dry or productive WOMEN ONLY CVA
Asthma Infection of the female genitalia Dizziness
Bronchitis Monthly self breast exam Severe Headaches
Emphysema Frequency of pap/pelvic exam Migraines
Pneumonia Date of last gyn exam? Seizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
Environmental allergies menarche age? Encephalitis
last CXR? menopause age? Meningitis
Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density & Result:
Cardiovascular MEN ONLY Mental Illness
Hypertension Infection of male genitalia/prostate? Depression
Hyperlipidemia Frequency of prostate exam? Once Schizophrenia
Chest pain / Angina Date of last prostate exam? 2012 Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus Weakness Measles
Rheumatic Fever Pain Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
Last EKG screening, when? 2/16/17 Arthritis Chicken Pox

University of South Florida College of Nursing Revision September 2014 10

Other: Other: Other:

General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?

Is there any problem that is not mentioned that your patient sought medical attention for with anyone? NO

Any other questions or comments that your patient would like you to know? NO

University of South Florida College of Nursing Revision September 2014 11

10 PHYSICAL EXAMINATION:

General Survey: Pt. is a Height: 170.2 cm Weight: 83.6 kg BMI Pain: (include rating and
65 y.o. male that appears Pulse: 88 Blood Pressure: (include location) location)
with no signs of distress. Respirations: 18 142/95 Right arm
He is alert and oriented None
x3.
Temperature: (route SpO2 : 92 Is the patient on Room Air or O2
taken?) Room air
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: Peripheral IV 20 gauge Location: right median cubital vein (antecubital fossa)
Date inserted: 2/15/17
Fluids infusing? no yes - what?

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 / mm Peripheral vision intact EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
Nose without lesions or discharge Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
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: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL CL LUL CL
RML CL LLL CL
RLL CL

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

Calf pain bilaterally negative Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: Carotid: Brachial: Radial: 97 Femoral: Popliteal: DP: PT:
No temporal or carotid bruits Edema: none [rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema: pitting non-pitting
Extremities warm with capillary refill less than 3 seconds

GI Bowel sounds active x 4 quadrants; no bruits auscultated No organomegaly

Percussion dull over liver and spleen and tympanic over stomach and intestine Abdomen non-tender to palpation
Last BM: (date 2 / 16 / 17 ) Formed Semi-formed Unformed Soft Hard Liquid
Watery
Color: Light brown Medium Brown Dark Brown Yellow Green White Coffee Ground Maroon Bright Red
Nausea emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: Clear Cloudy Color: yellow Previous 24 hour output: 275 mLs 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 _______ LUE _______ RLE & _______ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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

University of South Florida College of Nursing Revision September 2014 13

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.

Lab Dates Trend Analysis

ECG 2/15/17- 2/16/17 Normal sinus rhythm (77) Patient heart rate and
- Normal sinus rhythm electrical activity of the
(66) heart is within normal
limits. Decrease of HR
may be attributed to use
of metoprolol
(Lopressor).
Chest X-Ray 2/15/17 Cardiac silhouette is Patient is within normal
normal in size, Aorta is limits.
normal in appearance,
pulmonary vasculature
appears normal, no
pleural effusion, no
pneumothorax
Coronary Angiography 2/16/17 Severe 80% tubular Narrowing of right
w/ stent placement stenosis of a large right descending artery is the
posterior descending cause of NSTEMI and
artery. diagnosis of ACS. Patient
will need stent placement
to prevent further
ischemia, apoptosis, and
chest pain.
Chem Profile 2/15/17- 2/17/17 Troponin: 5.5, 5.8, 4.9 With the reference range
at 0.00- 0.07 ng/ml, these
values indicate extensive
damage to the
myocardium. A troponin
level this high is
indicative of a cardiac
event (NSTEMI).
Platelet: 138, 129, 140, Low level of platelets, or
121 thrombocytopenia, puts
the patient at risk for
bleeding. This low level
can be attributed to duel
platelet therapy with ASA
and Plavix.
2/17/17 Anti- XA: 1.0 , 0.7 High levels of Anti- XA
indicate that heparin
University of South Florida College of Nursing Revision September 2014 14
 therapy is above the
therapeutic threshold and
dosages should be held.

+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.)
Diet MCLS (Heart Healthy)
Telemetry monitoring,
constant vital sign monitoring,
No consults thus far.
Stent placement in right posterior descending artery: Resolute Integrity Drug Eluting Stent.
Duel platelet therapy with ASA and Plavix,
High intensity statin regimen with concurrent revisions on exercise and proper diet.

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

1. Activity intolerance related to insufficient oxygenation secondary to decreased cardiac output as evidenced by NSTEMI
following participation in vigorous activity.

2. Deficient knowledge related to disease and treatment plan as evidenced by excessive questioning.

3. Anxiety related to change in health status as evidenced by expressed concerns regarding lifestyle changes.

4. Risk for ineffective tissue perfusion related to occlusion of coronary arteries.

5. Risk for bleed related to Percutaneous Coronary Intervention and long term platelet therapy.

University of South Florida College of Nursing Revision September 2014 15

 15 CARE PLAN
Nursing Diagnosis: Activity intolerance related to insufficient oxygenation secondary to decreased cardiac output as evidenced by NSTEMI
Patient Goals/Outcomes
Patient will participate in
prescribed physical activity with
appropriate changes in heart rate, physical ability.
blood pressure, and breathing rate
twice in the twelve hour shift.
Patient will learn symptoms of
adverse effects of exercise and
learn when to report them by the
end of the shift.
following participation in vigorous activity.
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Nurse will assist patient with a six This walk test is a simple, safe, and Goal was not met as patient denied
minute walk test to determine inexpensive exercise test to predict assistance with walking around the
functional ability (Ackley & unit.
Ladwig, 2011).
Nurse will record and report the It is pertinent to report if the patient Goal was met and patient vital
clients ability to tolerate activity in is exhibiting any signs of distress signs stayed within normal limits.
respect to changes in HR, BP, RR, during activity to assess ability to
ECG changes, and reports of pain. partake in activity.
Nurse will educate patient on signs Being that the patient is knowledge Goal was met and patient was able
and symptoms of MI and the deficient on the disease process and to repeat several adverse effects.
necessary steps to take. the various symptoms, educating
and including the patient in the
treatment/prevention plan may be
conducive in helping the patient
redesign an activity plan that does
not cause distress.
Nurse will refer patient to cardiac A carefully monitored exercise Goal was met and included in
rehabilitation program for program can improve education patient discharge instructions.
education, evaluation, and guided and exercise capacity (Ackley &
support to increase activity and Ladwig, 2011).
rebuild life.

University of South Florida College of Nursing Revision September 2014 16

Include a minimum of one
Long term goal per care plan
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult Patient will need to learn an appropriate diet to follow to prevent further complications. Additionally, patient will need to learn
that concurrent compliance to diet plan is essential to therapeutic effect of atorvastatin (Lipitor).
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments Patient will need follow up appointments with the cardiologist to assess current condition.
Med Instruction/Prescription - Patient will need instructions on new medication regimens. These instructions were included in the discharge plan.
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 17

15 CARE PLAN
Nursing Diagnosis: Anxiety related to change in health status as evidenced by expressed concerns regarding lifestyle changes.
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
Patient will identify and verbalize Nurse will assist patient in Having the patient to identify Goal was met. Patient reported
symptoms of anxiety before the identifying feelings of anxiety. feelings of anxiety is an important feelings of anxiety and asked for
end of the shift. first step in alleviating the feeling. medication.
Patient will rate the feeling of Nurse will administer 0.5 mg Clonazepam is therapeutic in the Goal was met. Clonazepam was
anxiety below 3 two hours after clonazepam (Klonopin) PRN for management of anxiety. administered with the 0800
administration of antianxiety reports of anxiety. morning medication administration.
medication.
Nurse will explain all activities, Effective nurse-client Goal was met and patient reported
procedures, and issues that involve communication is critical to feeling less nervous about the
patient thoroughly and without efficient care (Ackley & Ladwig, disease process and necessary
medical jargon. 2011). lifestyle changes.

Include a minimum of one

Long term goal per care plan

University of South Florida College of Nursing Revision September 2014 18

 References

Ackley, B.J., Ladwig, G.B. (2011). Nursing diagnosis handbook: an evidence-based guide to planning care. St.
Louis, Missouri: Mosby Elsevier.

Halter, M.J. (2014). Relevant theories and therapies for nursing practice. In Foundations of Psychiatric Mental
Health Nursing (pp. 19-37). St. Louis, MO: Elsevier
Osborn, K. S., Wraa, C.E., Watson, A. B., Holleran, R. (2014). Caring for the patient with coronary artery
disease. In Medical- Surgical Nursing: Preparation for Practice(pp.1858-
1865). New York, NY: Pearson.
Vallerand, A.H., Sanoski, C.A., Deglin, J.H., Mansell, H.G. (2015). Daviss drug guide for nurses. Fifteenth
Edition. [Mobile application software]. Retrieved from: https://play.google.com/store/apps?hl=en.\

Willett, W.C. (2012). Dietary fats and coronary heart disease. Journal of Internal Medicine, 272(1), 13-24.
Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-
2796.2012.02553.x/full

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University of South Florida College of Nursing Revision September 2014 20