UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Andrew Harriman
Assignment Date: 19 May 2017
MSI & MSII PATIENT ASSESSMENT TOOL .
Agency: TGH/VCARE
1 PATIENT INFORMATION
Patient Initials: J.L. Age: 68yo Admission Date: 17 May 2017
Gender: M Marital Status: Divorced Primary Medical Diagnosis: Severe Aortic Stenosis
Primary Language: English
Level of Education: Bachelors degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Retired; AT&T management
Number/ages children/siblings: Three siblings, one son

Served/Veteran: No Code Status: Full

If yes: Ever deployed? Yes or No
Living Arrangements: Alone Advanced Directives: Yes
If no, do they want to fill them out?
Surgery Date: 17 May Procedure: Aortic valve
replacement
Culture/ Ethnicity /Nationality: White
Religion: None Type of Insurance: N/A

1 CHIEF COMPLAINT: Unable to be placed on liver transplant list until aortic valve is replaced.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Pt. went to his primary care 15 months ago for a routine appointment where it was discovered that he had a
murmur. Five days later he fell at home and was on the floor for approx. 8 hours. Pt. spent 30 days in Bayfront
due to multiple severe skin tears and for further testing. It was found that he was in liver failure. In December a
stress test, which was needed before he could be placed on transplant list, resulted in a diagnosis of
stenosis/ineffective valve. He had a TAVR test on May 1st. He is not eligible for a liver transplant until his valve
is replaced. His physician admitted him on the 17th to have the valve replacement surgery.

2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
July 2016 TIPS test
December 2016 Stress test (failed, unsure of exact results)
April 2017 Colonoscopy (Negative for any abnormalities)
University of South Florida College of Nursing Revision September 2014 1
 May 2017 TAVR procedure (successful)
1953 Tonsils removed
1996 HTN

Age (in years)

Environmental

Heart Trouble
2

Health

Stomach Ulcers
Bleeds Easily

Hypertension
Alcoholism

(angina, MI, DVT etc.)

Glaucoma
FAMILY

Kidney
Diabetes
Arthritis

Seizures
Anemia

Asthma

Problems

Problems
Cancer
Cause Allergies

Tumor
Stroke
Gout
MEDICAL of

Mental
HISTORY Death
(if
applicable)
Takotsubo
8
Father cardiomyo
4
pathy
8
Mother Alzheimers
0
7
Brother Alive X
0
5
Brother Alive
5
Sister 6
Alive
4
relationship

relationship

Comments: Patient does not have a close relationship with his brother and does not know when the a-fib was
diagnosed.

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? U X
Influenza (flu) (Date) Is within 1 years? October 2016 X
Pneumococcal (pneumonia) (Date) Is within 5 years? U 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 Causative Agent
Type of Reaction (describe explicitly)
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) (I picked aortic stenosis since that is the problem that he is currently here for.)

Aortic stenosis is the narrowing of the aortic valve opening. According to Huether and McCance (2017), aortic
stenosis is the most common valvular abnormality and affects nearly 2% of adults over 65 years of age. Aortic
stenosis is associated with many risk factors, including smoking and hypertension, both of which are part of this
patients history. As the opening in the valve narrows, it takes more and more force for the left ventricle to
empty its contents into the aorta. Over time this will cause thickening of the left ventricle, also known as
ventricular hypertrophy. As the hypertrophy increases, so too will the myocardial oxygen demand. Eventually
this will lead to ischemia and can eventually lead to STEMI/NSTEMI events or even death.

Classic symptoms of aortic stenosis include dyspnea, chest pain, syncope, murmur or palpitations (American
Heart Association, 2016).

While vasodilator therapy can help temporarily improve symptoms, the only long-term treatment for severe
stenosis is a surgical valve replacement using either a mechanical or bioprosthetic valve.

5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation),
routine, and PRN medication . Give trade and generic name.]
Name Spironolactone (Aldactone) Concentration 50mg/tab Dosage Amount 50mg

Route Oral Frequency QD

Pharmaceutical class Antihypertensive/diuretics Both
Indication Hypertension
Adverse/ Side effects Dizziness, drowsiness, lethargy, weakness, hypotension, Stevens-Johnson Syndrome, hypokalemia
Nursing considerations/ Patient Teaching Take same time each day, monitor weight biweekly, change positions slowly.

Name Bumex (Bumetanide) Concentration 1mg/tab Dosage Amount 1 mg

Route Oral Frequency QD

Pharmaceutical class Diuretic Both
Indication Edema due to hepatic disease
Adverse/ Side effects Dizziness, encephalopathy, headache, hearing loss, tinnitus, Stevens-Johnson Syndrome
Nursing considerations/ Patient Teaching Take a directed, no double dosing, change positions slowly, use sunscreen and protective clothing.

University of South Florida College of Nursing Revision September 2014 3

Name Lantus (insulin glargine injection) Concentration 100units/ml Dosage Amount 10u

Route Subcu Frequency QD

Pharmaceutical class Antidiabetic Hospital
Indication Control of hyperglycemia
Adverse/ Side effects Hypoglycemia, hypokalemia, pruritis, erythema, swelling, anaphylaxis
Nursing considerations/ Patient Teaching Teach proper technique for administration, explain that it controls hyperglycemia but does not cure diabetes, instruct patient in
proper testing of serum glucose and ketones.

Name Metformin (Glucophage) Concentration 500mg/tablet Dosage Amount 500mg

Route Oral Frequency TID

Pharmaceutical class antidiabetics Both
Indication Management of type 2 diabetes
Adverse/ Side effects Abdominal bloating, diarrhea, nausea, vomiting, lactic acidosis
Nursing considerations/ Patient Teaching Take at the same time everyday, follow prescribed diet

Name Rifaximin (Xifaxin) Concentration 550mg/tab Dosage Amount 550mg

Route Oral Frequency BID

Pharmaceutical class anti-infectives Hospital
Indication Reduction in risk of overt hepatic encephalopathy recurrence
Adverse/ Side effects Ataxia, confusion, drowsiness, fatigue, headache, weakness, red discoloration of tears, abdominal pain, diarrhea, flatulence, heartburn, nausea
Nursing considerations/ Patient Teaching Dont skip or double up on doses, notify HCP if S&S of hepatitis occur, limit alcohol intake

Name Norco (APAP/hydrocodone) Concentration 5mg/tab Dosage Amount 5mg

Route Oral Frequency Q 8 hrs

Pharmaceutical class Opioid Hospital
Indication Pain management
Adverse/ Side effects Confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea
Nursing considerations/ Patient Teaching Take as directed, liver damage may result from prolonged use, instruct how and when to ask for and take pain meds

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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? Low sodium 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:
Breakfast: Blueberries/yogurt, scrambled eggs, coffee

Lunch: Sandwich on whole grain

Dinner: Meat of some kind, veggies

Snacks: sugar free mints

Liquids (include alcohol): coffee, diet cranberry juice, diet

soda, tea

As can be seen by the graph the patient is eating his

recommended daily intake of proteins but is falling
short of his other goals. These proportions are not
conducive to a heart healthy diet due to being low in
fiber and sodium. Sodium causes the body to retain
water. When the body retains water it forces the heart
to work harder since it has more volume to circulate
through the body. Therefore, people with a cardiac
history need to be on a lower sodium diet. This patient
is also pre-diabetic and should be eating starchy foods
which release their energy slowly and help to maintain
a steady blood sugar level and A1C instead of causing
spikes in blood sugar levels. While diet soda may
sound like a good alternative, it still has a negative
effect on the body and should be consumed sparingly,
if at all.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill? Son

How do you generally cope with stress? or What do you do when you are upset? I avoid it. When pressed further patient
responded What the hell do you want me to say, that I cry or something?

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
N/A

+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
University of South Florida College of Nursing Revision September 2014 5
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No If yes,
have you sought help for this? N/A

Are you currently in a safe relationship? Im not in any relationship.

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. Self absorption/Stagnation X 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: The task of this stage is the acceptance of ones life, worth, and eventual death. Ego
integrity reflects a satisfaction with life and an understanding of ones place in the life cycle. A sense of loss,
discomfort with life and aging, and a fear of death are seen in despair. (Treas & Wilkinson, 2014)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
This patient is in the ego integrity stage of ego integrity vs. despair. Even though he is retired, he had a very
successful career with AT&T. He is close with his son and even though he is divorced he does not appear to
have any regrets. In fact, he seems quite satisfied being divorced stating Its the best thing that ever happened
to me. He also made several comments about how successful he was in his career.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life: It does not appear that this hospitalization has had any impact on this patient other than to annoy him.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? I have no idea. Thats why Im here. Let these guys figure it out.

What does your illness mean to you? Its the difference between getting a transplant and not getting one.

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

Have you ever been sexually active? Yes

Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? How the hell should I know?
Have you or your partner received the Gardasil (HPV) vaccination? Unknown

Are you currently sexually active? No If yes, are you in a monogamous relationship? N/A When sexually active, what
measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? N/A

How long have you been with your current partner? N/A

Have any medical or surgical conditions changed your ability to have sexual activity? N/A

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
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University of South Florida College of Nursing Revision September 2014 7
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
Thats my business.

Do your religious beliefs influence your current condition?

Patient refused to answer.

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

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes
How much?(specify daily
If so, what? For how many years? 40 years
amount)
Cigarettes 2 packs (age 17 thru 57)

If applicable, when did the

Pack Years: 80
patient quit? 11 years ago

Does anyone in the patients household smoke tobacco? No Has the patient ever tried to quit? Yes
If so, what, and how much? If yes, what did they use to try to quit? Patch

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes
What? Beer/liquor How much? Social For how many years?
Volume: 10 drinks/week (age 18 thru 67)
Frequency: 2/day
If applicable, when did the patient quit? July 2016

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? No
If so, what?
How much? For how many years?
(age thru )

Is the patient currently using these drugs? Yes If not, when did he/she
No quit?

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

5. For Veterans: Have you had any kind of service related exposure?
N/A

University of South Florida College of Nursing Revision September 2014 8

 10 REVIEW OF SYSTEMS NARRATIVE

Gastrointestinal Immunologic
Nausea, vomiting, or diarrhea Chills with severe shaking
Constipation Irritable
Integumentary Night sweats
Bowel
GERD
Changes in appearance of skin Fever
Cholecystitis
Indigestion Gastritis /
X Problems with nails-brittle HIV or AIDS
Ulcers
Hemorrhoids Blood in
Dandruff Lupus
the stool
Psoriasis Yellow jaundice Hepatitis Rheumatoid Arthritis
Hives or rashes Pancreatitis Sarcoidosis
Skin infections Colitis Tumor
X Use of sunscreen Yes Life threatening allergic
Diverticulitis
SPF: 15 reaction
Bathing routine: daily Appendicitis Enlarged lymph nodes
Other: Abdominal Abscess Other:
Be sure to answer the highlighted area X Last colonoscopy? April 2017
HEENT Other: Hematologic/Oncologic
Difficulty seeing Genitourinary Anemia
Cataracts or Glaucoma nocturia X 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:
Normal frequency of urination: 6-
Post-nasal drip Other: plasma
8 x/day
Oral/pharyngeal infection Bladder or kidney infections
Dental problems Metabolic/Endocrine
X Routine brushing of teeth 2x/day Diabetes Type:
X Routine dentist visits
Hypothyroid /Hyperthyroid
1x/year
X Vision screening: every 2 years 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
Ticks or Tremors
irregular
Environmental allergies menarche age? Encephalitis
X Last CXR? 18 May 2017 menopause age? Meningitis

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Other: Date of last Mammogram &Result: Other:
Date of DEXA Bone Density &
Cardiovascular MEN ONLY Mental Illness
Infection of male
Hypertension Depression
genitalia/prostate?
Hyperlipidemia Frequency of prostate exam? Schizophrenia
Chest pain / Angina Date of last prostate exam? N/A Anxiety
Myocardial Infarction BPH Bipolar
CAD/PVD Urinary Retention Other:
CHF Musculoskeletal
Murmur Injuries or Fractures Childhood Diseases
Thrombus X Weakness X Measles
Rheumatic Fever Pain X Mumps
Myocarditis Gout Polio
Arrhythmias Osteomyelitis Scarlet Fever
X Last EKG screening, when? 18
Arthritis X Chicken Pox
May 2017
Other: Other: Other:

General Constitution
Recent weight loss or gain: No
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. What else is there?

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

University of South Florida College of Nursing Revision September 2014 10

10 PHYSICAL EXAMINATION:

General Survey: Height: 72in Weight: 192 BMI: Pain: (include rating and
Unknown location)
Pulse: 84 Blood Pressure: (include location)
Respirations: 22 117/56, left upper arm 0/10
Temperature: (route SpO2: 100% Is the patient on Room Air or O2
taken?) 98.7-oral RA
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
X 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]

X awake, calm, relaxed, interacts well with others, judgment intact

Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]

X clear, crisp diction

Mood and Affect: X pleasant X cooperative cheerful X talkative quiet boisterous flat
apathetic bizarre agitated anxious tearful withdrawn aggressive hostile loud
Other:
Integumentary
X Skin is warm, dry, and intact X Skin turgor elastic X No rashes, lesions, or deformities
X Nails without clubbing X Capillary refill < 3 seconds X Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Central access device Type: Location: Date inserted:
Fluids infusing? X no yes - what?

HEENT: X Facial features symmetric X No pain in sinus region X No pain, clicking of TMJ X Trachea midline
X Thyroid not enlarged X No palpable lymph nodes X sclera white and conjunctiva clear; without discharge
X Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
X PERRLA pupil size / mm X Peripheral vision intact X EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge Whisper test heard: right ear- inches & left ear- inches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Pt. refused whisper test.

Pulmonary/Thorax: X Respirations regular and unlabored X Transverse to AP ratio 2:1 X Chest expansion symmetric
X Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin Amount: scant small moderate large
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds: Clear in all fields
RUL LUL
RML LLL
RLL

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

Cardiovascular: X No lifts, heaves, or thrills

University of South Florida College of Nursing Revision September 2014 11

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

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

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

X Percussion dull over liver and spleen and tympanic over stomach and intestine X Abdomen non-tender to palpation
Last BM: (date 19/May/2017) Formed
Color: Medium Brown
Nausea Emesis Describe if present:
Genitalia: Clean, moist, without discharge, lesions or odor X Not assessed, patient alert, oriented, denies problems
Other Describe:

GU Urine output: X Clear Cloudy Color: Previous 24 hour output: Approx. 2,000 mLs
Foley Catheter Urinal or Bedpan Bathroom Privileges without assistance
CVA punch without rebound tenderness

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at ___5____ RUE ____5___ LUE ___5____ RLE & ___5___ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
X Vertebral column without kyphosis or scoliosis
X Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia

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

University of South Florida College of Nursing Revision September 2014 12

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

Na 135 18 May Sodium has stayed within normal limits

K 4.1 18 May Potassium has stayed within normal limits
Cl 105 18 May Chloride has stayed within normal limits
Sugar 155 18 May Sugar is trending downward slightly
BUN 29 18 May BUN has stayed within normal limits
Creatinine 1.1 18 May Creatinine has stayed within normal limits
(All labs are within expected ranges except for glucose.)

+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.)
Pt. is receiving accuchecks b.i.d.
SCDs to be used as long as pt. tolerates them for prevention of DVTs.
Pt. to be discharged this afternoon.
Pt. instructed when and how to change dressings at insertion sites.
Pt. taught signs and symptoms of infection.

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

1. Risk for infection r/t valve replacement

2. Decreased cardiac output r/t cardiac dysfunction

3. Activity intolerance r/t lack of adequate oxygenation

University of South Florida College of Nursing Revision September 2014 13

 15 CARE PLAN
Patient Goals/Outcomes
Long Term: Patient will remain
free from symptoms of infection
during contact with health care
providers.
University of South Florida College of Nursing Revision September 2014
Nursing Diagnosis: Risk for infection r/t aortic valve replacement
Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
- Implement targeted surveillance -Universal screening for MRSA -Pt. was educated on the proper
for methicillin- increased screenings and costs but techniques of hand hygiene. He
resistant Staphylococcus aureus. resulted in few additional cases agreed to point out to any member
being detected. Where MRSA is of the care team if they did not
- Note and report laboratory values endemic, targeted screening properly clean their hands upon
(e.g., white blood cell count and remains the most efficient strategy entering his room. Patient did
differential, serum protein, serum for early identification of MRSA- instruct a Resident, who failed to
albumin, and cultures). positive clients (Creamer et al, wash his hands, to use sanitizer
2012, as cited from Ackley, et al., before beginning his assessment of
- Assess skin for color, moisture, 2014). the patient. This event was
texture, and turgor (elasticity). witnessed by both the primary RN
Keep accurate, ongoing - While the white blood cell count and the nursing student.
documentation of changes. may be in the normal range, an
increased number of immature
- When using an alcohol-based bands may be present (Versalovic
hand rub, apply ample amount of etal, 2011, as cited from Ackley, et
product to palm of one hand and al., 2014).CEBN:A neutropenic
rub hands together, covering all client with fever represents an
surfaces of hands and fingers, until absolute medical emergency
hands are dry. Note that the volume (Mahtani, 2010, as cited from
needed to reduce the number of Ackley, et al., 2014).
bacteria on hands varies by
product. - A number of instruments have
been developed to assess for risk of
pressure ulcers, including the
Braden scale, the Norton scale, and
the Waterlow scale. All three scales
include items related to activity
mobility, nutritional status,
incontinence, and cognition
14

Short Term: Patient will
demonstrate appropriate care of
infection-prone sites within 48
hours of instruction.
University of South Florida College of Nursing Revision September 2014
-Observe and report signs of
infection such as redness, warmth,
discharge, and increased body
temperature.
-Carefully wash and pat dry skin,
including skinfold areas. Use
hydration and moisturization on all
at-risk surfaces.
- Recommend responsible use of
antibiotics; use antibiotics
sparingly.
- Recommend that the geriatric
client receive an annual influenza
immunization and one-time
(Agency for Healthcare Quality
and Research, 2011, as cited from
Ackley, et al., 2014).
- Adequate hand antisepsis reduces
infection rates. The use of alcohol-
based hand rubs is particularly
effective; in contrast to
handwashing, hand rubs kill
susceptible bacteria more rapidly
and to a greater extent, and are less
time-consuming, and skin health is
better preserved when moisturizers
are added (Aitken etal, 2011;Hass,
2014, as cited from Ackley, et al.,
2014).
-Change in mental status, fever, Patient was educated about the
shaking, chills, and hypotension proper equipment, techniques and
are indicators of sepsis (Risi, 2009, instructions on how to keep
as cited from Ackley, et al., 2014). surgical sites free of infection.
Using supplies provided by nurse,
-Application of moisturizers he demonstrated the techniques that
containing humectants is clearly had been taught to him.
effective in enhancing skin barrier
function (Kottner etal, 2013, as
cited from Ackley, et al., 2014).
- Use and misuse of antibiotics
diminishes their therapeutic benefit
and facilitates the development of
multidrug-resistant organisms
(MDROs) and-associated disease,
and increases health care costs.
15

Long Term: Demonstrate adequate
cardiac output as evidenced by
blood pressure, pulse rate and
rhythm within normal parameters
for client; strong peripheral pulses;
maintained level of mentation, lack
of chest discomfort or dyspnea, and
adequate urinary output; an ability
to tolerate activity without
symptoms of dyspnea, syncope, or
chest pain
Short Term: Explain actions and
precautions to prevent cardiac
disease.
University of South Florida College of Nursing Revision September 2014
pneumococcal vaccine.
- Monitor and report presence and
degree of symptoms including
dyspnea at rest or with reduced
exercise capacity, orthopnea,
paroxysmal nocturnal dyspnea,
nocturnal cough, distended
abdomen, fatigue, or weakness.
Monitor and report signs including
jugular vein distention, S3 gallop,
rales, positive hepatojugular reflux,
ascites, laterally displaced or
pronounced point of maximal
impact, heart murmurs, narrow
pulse pressure, cool extremities,
tachycardia with pulsus alternans,
and irregular heartbeat.
- Recognize primary characteristics
of decreased cardiac output as
fatigue, dyspnea, edema,
orthopnea, paroxysmal nocturnal
Antibiotic stewardship is essential
in reducing current and future
resistance in bacteria (Moody etal,
2012, as cited from Ackley, et al.,
2014).
- Immunization against influenza is
an effective intervention that
reduces serologically confirmed
cases.
- These are symptoms and signs
consistent with heart failure (HF)
and decreased cardiac output
(Yancy etal, 2013, as cited from
Ackley, et al., 2014).EB:In a study
of primary care clients,
breathlessness during exercise,
limitations in physical activity, and
orthopnea were the three most
significant symptoms most often
associated with HF (Devroey &
Van Casteren, 2011, as cited from
Ackley, et al., 2014)
- A nursing study to validate Patient was educated on the signs
characteristics of the nursing and symptoms of cardiac disease.
diagnosis decreased cardiac output He acknowledged that he
in a clinical environment identified understood that both tobacco (to
16
 dyspnea, and increased CVP. and categorized related client include second hand smoke) and
Recognize secondary characteristics that were present as alcohol can contribute to cardiac
characteristics of decreased cardiac primary or secondary (Martins disease. The importance of a
output as weight gain, etal, 2010, as cited from Ackley, et healthy, well-balanced died was
hepatomegaly, jugular venous al., 2014). also stressed to the patient.
distention, palpitations, lung
crackles, oliguria, coughing, - These are symptoms and signs
clammy skin, and skin color consistent with heart failure (HF)
changes. and decreased cardiac output
(Yancy etal, 2013, as cited from
- Monitor and report presence and Ackley, et al., 2014).
degree of symptoms including
dyspnea at rest or with reduced
exercise capacity, orthopnea,
paroxysmal nocturnal dyspnea,
nocturnal cough, distended
abdomen, fatigue, or weakness.
Monitor and report signs including
jugular vein distention, S3 gallop,
rales, positive hepatojugular reflux,
ascites, laterally displaced or
pronounced point of maximal
impact, heart murmurs, narrow
pulse pressure, cool extremities,
tachycardia with pulsus alternans,
and irregular heartbeat.

- Remain free of side effects from
the medications used to achieve
adequate cardiac output
- Recognize that blood pressure
control is beneficial for older
clients to reduce the risk of
worsening HF
- Monitor orthostatic blood
pressures and daily weights.
- Hypertension treatment is
particularly beneficial in the older
population, and control of both
systolic and diastolic hypertension
has been shown to reduce the risk
of incident HF (Yancy etal, 2013,
as cited from Ackley, et al., 2014).

- These interventions assess for

University of South Florida College of Nursing Revision September 2014 17
 fluid volume status (Yancy etal,
2013, as cited from Ackley, et al.,
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
X Dietary Consult
X PT/ OT
Pastoral Care
X Durable Medical Needs
F/U appointments
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
X Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014 18

 References

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

Maryland Heights, Mo: Mosby/Elsevier.

American Heart Association. (2016, May). Problem:Aortic Valve Stenosis. Retrieved June 13, 2017, from

American Heart Association: http://www.heart.org/HEARTORG/Conditions/More/

HeartValveProblemsandDisease /Problem-Aortic-Valve-Stenosis_UCM_450437_Article.jsp#.WUh_L8b-

1E4

Food Tracker Graph retrieved from https://www.supertracker.usda.gov/foodtracker.aspx

Huether, S.E., & McCance, K.L. (2017). Understanding pathophysiology. St. Louis, MO:Elsevier

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

Davis Company.

Vallerand, A., Sanoski, C., & Deglin, J. H. (2014). Davis's Drug Guide for Nurses. Philadelphia, US: F. A.

Davis Company.

TOTAL score: 89
Overall, the PAT included specific and individualized needs and issues related to this patient. The diagnostic
section was minimalistic.

University of South Florida College of Nursing Revision September 2014 19

University of South Florida College of Nursing Revision September 2014 20