UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
2 CC: I have felt so dizzy, as though I cannot stand up or I will faint. My heart has been feeling fluttery and
my chest and back hurts. I was hurting all over and feeling weak and my head was pounding. I still feel
headaches at times.
3 HPI: (OLD CART) The patient is an !year!old "uban!#merican female who presented to the $% on
&'()'*&, accompanied by her daughter, complaining of dizziness and near syncope. +he was admitted that same evening,
#nd was diagnosed with atrial fibrillation with rapid ventricular rate ,#-ib with ./.0. ./. rates were in the *&1s!*21s.
3er rate spontaneously decreased overnight, then spiked again in the morning, into the ./. range of *22. The patient
3as a history of #-ib and "/# with residual left!sided weakness. +he says she has been on "oumadin until suffering a
4I bleed within the past few years, so this regimen was stopped. "urrently, the patient only takes aspirin and 5lavi6 at
3ome. The onset of the syncopal episode was &'(). +he feels transient dizziness and headaches. The duration is usually
&1 minutes. #ggravating factors include ambulation and changing positions 7uickly. # relieving factor is rest with
Minimal e6ertion and movement. "urrent treatment includes bed rest and pillows under her legs and behind her head.
The severity of her pain varies between a two and eight out of ten.
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*(
+tudent; %eanne <uchholtz
PATIENT ASSESSMENT TOOL .
#ssignment %ate; &'(='*&

#gency; +t. >oe?s
5atient Initials; @# #ge; #dmission %ate;&'()'*&
4ender; -emale Marital +tatus; +ingle 5rimary Medical %iagnosis with I"%!*1 code;
#trial -ibrillation with .apid /entricular .ate
5rimary Aanguage; +panish 9o I"%!*1 code could be ascertained.
Aevel of $ducation; 3igh +chool @ther Medical %iagnoses; 36 of # -ib and
hyperlipidemiaB with remote h6 of 3T9
@ccupation ,if retired, what fromC0; .etired, school teacher, grade 2
9umber'ages children'siblings; Two children, ages D1 ,son0 and )E
,daughter0. 5atient does not have any siblings
"ode +tatus; -ull "ode
Aiving #rrangements; 5atient lives in an assisted living facility and
is visited fre7uenty by her children.
#dvanced %irectives; 9one
+urgery %ate; &'(D'*& 5rocedure; "atheter
ablationfor rhythm reset
"ulture' $thnicity '9ationality; "uban!#merican
.eligion; .oman "atholic Type of Insurance; Medicare
*
2 PMH/PSH 3ospitalizations for any medical illness or operation
Date Opeat!"# " I$$#e%% Ma#a&e'e#t/Teat'e#t
(11= 5resented to $% with similar symptoms and "ardiologist consult placed her on "oumadin
#dmitted overnight. $F4 revealed arrhythmia .egimen.
Gith partial #/ block
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( (
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MI H H H H
Mother

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"omments; <oth parents had history of 3T9, but father had no other apparent or diagnosed health problems. 3e suffered an acute MI
* years ago. 5atient claims her mother passed away of old age. +he is unaware of the health history of any other close relatives.
( IMMUNI)ATION HISTORY
YES NO
.outine childhood vaccinations H
.outine adult vaccinations for military or federal service H
#dult %iphtheria ,%ate0 5atient is unaware of having received this
#dult Tetanus ,%ate0 (11E H
Influenza ,flu0 ,%ate0 (1*( H
5neumococcal ,pneumonia0 ,%ate0 (1*( H
3ave you had any other vaccines given for international travel or
occupational purposesC 5lease Aist H
( A$$e&!e% "
A*+e%e Rea,t!"#%
9#M$ of
"ausative #gent
Type of .eaction ,describe e6plicitly0
Medications
5atient has no 9one
Fnown allergies to
Medications.
@ther ,food, tape,
dye, etc.0
5atient also denies 9one
#ny allergies to
-ood, tape, dye, etc
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( &
- PATHOPHYSIOLOGY: ,include #5# reference0 (!#,$.*e a#/ &e#et!, 0a,t"% !'pa,t!#& t1e *!a&#"%!%2
p"&#"%!% " teat'e#t) #trial fibrillation is a continuous or paro6ysmal arrhythmia, characterized by rapid, chaotic electrical
#ctivity and an irregularly irregular ventricular response ,Mc4uiness and >offe, (1*&0. In most patients there is an associated
.apid ventricular rhythm due to the #/ node in the heart being overwhelmed with non!stop electrical impulses in the atria. #trial
-lutter is similar, however, the rate is organized and appears as a sawtooth pattern instead of chaotic peaks and dips. .isk factors are
#ge, a history of hypertension, valvular disease, coronary artery disease, acute myocardial infarction, cardiomyopathy, congestive
3eart failure, embolism, pneumonia, digo6in to6icity, and hyper! or hypothyroidism. +ymptoms vary per patient, from none to severe.
+evere symptoms present as angina ,chest pain0, dyspnea ,difficulty breathing0, and syncope ,fainting0. %uring a physical e6am , an
Irregularly irregular pulse and tachycardia will be noted. %iagnosis includes an $F4 revealing low!amplitude chaotic waves, lacking
%iscernible 5 waves and an irregular I.+ comple6. Aabs including T+3 ,to check thyroid viability0, "<", and 5T'I9. are drawn
To determine altered tissue perfusion and risk for emboli. #trial fibrillation is treated by controlling the heart?s ventricular rate
Through cardioversion or catheter ablation to reset the rhythm. In some instances, a pacemaker may be inserted. %epending on the
+everity and duration of the fibrillation, the prognosis may be positive. It is important to treat the underlying etiology, such as
3ypertension. In severe cases, as seen in advanced!stage diseases, treatment is mainly palliative and includes a monitored anti!
"oagulant therapy regimen to reduce the risk for emboli. In some cases, the cessation of ethanol consumption may reduce symptoms.
.are cases of genetically!linked atrial fibrillation have been noted, but limited information regarding diagnosis, prognosis, and
Treatment e6ists. There are ongoing efforts to identify these genetic etiologies. M,G.!#e%% a#* 3"00e (24(32 Ap!$ 3). 5At!a$
F!6!$$at!"# a#* At!a$ F$.tte72 -8M!#.te C$!#!,a$ C"#%.$t2 Nursing Central. Ret!e+e* 0"':
HTTP://999.UN:OUNDMEDICINE.COM/NURSINGCENTRAL/U:/VIE9/-8MINUTE8CLINICAL8
CONSULT/((;<;-/ALL/ATRIAL=FI:RILLATION=AND=ATRIAL=FLUTTER
- MEDICATIONS: ,Include both prescription and @T"0
Na'e #+# C"#,e#tat!"# 9# D"%a&e A'".#t * mg
R".te 5@ Fe>.e#,/ *6 daily
P1a'a,e.t!,a$ ,$a%% anticoagulant'antiplatelet
H"'e H"%p!ta$ " :"t1
I#*!,at!"# anti!inflammatoryB prophyla6is of ischemic stroke and embolus
SE8 4I discomfort and pain, #/+, elevations in <89 and "reatinine, increased bleeding risk
Na'e "lopidogrel ,5lavi60 C"#,e#tat!"# 9# D"%a&e A'".#t DE mg
R".te 5@ Fe>.e#,/ *6 daily
P1a'a,e.t!,a$ ,$a%% antiplatelet
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 8seful with #+# to decrease risk for venous thromboembolus ,/T$0
SE8 .isk for ulcers, increased bleeding risk, and thrombocytopenia, fatigue
Na'e +imvastatin C"#,e#tat!"# 9# D"%a&e A'".#t (1 mg
R".te 5@ Fe>.e#,/ *6 daily
P1a'a,e.t!,a$ ,$a%% 3M4!"o# reductase inhibitor
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 3yperlipidemia SE8 "onstipation, headache, angina, remote cases of +tevens!>ohnsons syndrome
Na'e @6ycodone ,5ercoset0 C"#,e#tat!"# 9# D"%a&e A'".#t * tablet
R".te 5@ Fe>.e#,/ 72hr
P1a'a,e.t!,a$ ,$a%% +ynthetic opioid analgesis
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 5.9 for pain
SE8 %rowsiness, rash, amaphyla6is, paranoia, may be habit!forming
Na'e %iphenhydramine ,<enadryl0 C"#,e#tat!"# 1.(E mA D"%a&e A'".#t *(.E mg
R".te I/ InJection Fe>.e#,/ @nce
P1a'a,e.t!,a$ ,$a%% #ntihistamine
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 5.9 itching
SE8 %rowsiness and sedation, impaired motor skills, confusion, nausea, dry mouth, hypotension, tachycardia
Na'e Meperidine ,%emerol0 C"#,e#tat!"# * mA D"%a&e A'".#t (E mg
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R".te I/ inJection Fe>.e#,/ @nce
P1a'a,e.t!,a$ ,$a%% @pioid, similar to morphine
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 5.9 rigors
SE8 .isk for respiratory suppression, confusion, risk for dependence
Na'e Midazolam ,/ersed0 C"#,e#tat!"# * mA D"%a&e A'".#t * mg
R".te I/ inJection Fe>.e#,/ @nce, 7Eminutes
P1a'a,e.t!,a$ ,$a%% #n6iolytic
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 5.9 agitation'an6iety
SE8 %rowsiness, blurred vision, nausea, bradycardia, cough'wheeze
Na'e @ndansetrron ,Kofran0 C"#,e#tat!"# ( mA D"%a&e A'".#t 2 mg
R".te I/ inJection Fe>.e#,/ @nce
P1a'a,e.t!,a$ ,$a%% +elective E!3T& receptor agonist
H"'e H"%p!ta$ " :"t1
I#*!,at!"# 5.9 nausea'vomiting
SE8 3eadache, constipation, bradycardia, syncope
Na'e C"#,e#tat!"# D"%a&e A'".#t
R".te Fe>.e#,/
P1a'a,e.t!,a$ ,$a%%
H"'e H"%p!ta$ " :"t1
I#*!,at!"#
Na'e C"#,e#tat!"# D"%a&e A'".#t
R".te Fe>.e#,/
P1a'a,e.t!,a$ ,$a%%
H"'e H"%p!ta$ " :"t1
I#*!,at!"#
Na'e C"#,e#tat!"# D"%a&e A'".#t
R".te Fe>.e#,/
P1a'a,e.t!,a$ ,$a%%
H"'e H"%p!ta$ " :"t1
I#*!,at!"#
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< NUTRITION: ,Include; type of diet, (2 3. average home diet, (2 3. diet recall, your nutritional analysis0
D!et "*ee* !# 1"%p!ta$? Ca*!a, *!et
:ea@0a%t: * egg omelet with margarine, * piece whole grain
toast, ) oz cranberry Juice, * c orange slices L.#,1: 2 oz grilled
A#a$/%!% "0 1"'e *!et (C"'pae t" 0""* p/a'!* a#*
C"#%!*e ,"8'"6!*!t!e% a#* ,.$t.a$ ,"#%!*eat!"#%):
"hicken sandwhich on whole grain bun with veggies only, oz
unsweet iced tea D!##e: ) oz blackened tilapia with roasted
asparagus made with margarine, no salt, * small white dinner roll,
and water with lemon S#a,@: * c sugar free Jello
#fter an alysis of the patient?s home diet, it is apparent that
+he is missing out on some necessary nutrients to benefit her
health. The target for whole grains is )oz, and she is only
satisfying &.E oz of that. I would recommend she add a slice
D!et pt 0"$$"A% at 1"'e? @f whole grain toast to breakfast, or substitute whole grain
:ea@0a%t; L c oatmeal made with water, *c lowfat yogurt, oz
orange Juice
"rackers for the .itz ones that are both high in fat and are
made with refined carbohydrates. The patient satisfies her daily
9eeds for fruit, but misses out on almost half the needed (.Ec
L.#,1: 2 oz tuna mi6ed with (tbs mayonnaise and relish, E .itz
crackers, oz diet5epsi
@f vegetables. # recommendation I would make is to add a
small salad to lunch, made with romaine instead of iceberg.
+he is almost at her limit for fats, *2g out of the allotted ((g,
D!##e: +touffer?s individual lasagna with beef, * c green beans
in butter,
3owever some of that comes from the full!fat mayo at lunch.
+he could easily swap out for a low!fat version, and also add (
tbs of heart!healthy olive oil to her salad to satisy her needs.
oz unsweet iced tea To make up for the missing ounce of protein needed in her diet,
S#a,@%: small sliced apple with caramel sauce I recommend she do away with the caramel sauce that adds to
$mpty calories, fat, and sugar, and instead use ( tbs of low!fat
5eanut butter with her apple. +he?ll get protein and heart!
healthy omega & fatty acids. #nother way to add protein is to
swap out the calorie!free soda for nutritious low!fat milk.
USDA (#.*.). S.peta,@e: F""* ta,@e. Ret!e+e* 0"':
1ttp%://AAA.%.peta,@e..%*a.&"+/0""*ta,@e.a%pB?
Cat&"/IDC8(DF""*De%,!pt!"#
Eat 1ea$t1/: :e a,t!+e ,"''.#!t/ A"@%1"p%. (24(22 Ap!$).
Ret!e+e* 0"':
1ttp://AAA.,1""%e'/p$ate.&"+/*"A#$"a*%/EatHea$t1/:eA,t!+eC"
''.#!t/9"@%1"p%.p*0
2 COPING ASSESSMENT/SUPPORT SYSTEM: ,these are prompts designed to help guide your discussion0
Gho helps you when you are illC I have a nurse at the #A- and also my children come to visit me.
3ow do you generally cope with stressC or Ghat do you do when you are upsetC I enJoy praying and reading
scriptures.
I used to Journal but my hand shakes now with old age. Ghen I am upset, I pray and say the rosary. My children come
to
+ee me often, and also I have a few friends and the #A- that I can talk to.
.ecent difficulties ,-eelings of depression, an6iety, being overwhelmed, relationships, friends, social life0
My growing pain gives me an6iety. I have woken up feeling so dizzy and have a panic attack because I feel like I can?t
<reathe. I do feel somewhat, depressed about it, yes, because it makes me feel out of control.
E2 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
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safe.
3ave you ever felt unsafe in a close relationshipC MMM9o
3ave you ever been talked down toCMMMMMM9oMMMMMMM 3ave you ever been hit punched or slappedC MMMMM9oMMMMM
3ave you been emotionally or physically harmed in other ways by a person in a close relationship with youC
MMMMMMMMMMMM9oMMMMMMMMMMMMMMMMMMMMMMMM If yes, have you sought help for thisC MMMM9#MMMMMMMM
#re you currently in a safe relationshipC
My husband died ten years ago from cancer. I am not in any romantic relationship. <ut my friends and family do make
Me feel safe.
- DEVELOPMENTAL CONSIDERATIONS:
$rikson?s stage of psychosocial development; Trust vs. Mistrust #utonomy vs. %oubt N +hame Initiative vs. 4uilt Industry
vs. Inferiority Identity vs. .ole "onfusion'%iffusion Intimacy vs. Isolation 4enerativity vs. +elf absorption'+tagnation H$go Integrity vs.
%espair
4ive the te6tbook definition of both parts of $rickson?s developmental stage for your patient?s age group; #ccording to $rikson?s
+tages of 4rowth and %evelopment ,@sborn, Graa, and Gatson, (1*10, during this stage the older adult will e6amine in
.etrospect his or her life and whether or not that life was worth living. If that person?s life can be viewed in a positive light,
3e or she is said to be e6hibiting $go Integrity. "onversely, if that person feels a sense of worthless in regard to living, he or she is
said to have %espair. O%6"#2 9aa2 9at%"#. (24(4). Me*!,a$8 S.&!,a$ N.%!#&: Pepaat!"# 0" Pa,t!,e. Uppe Sa**$e
R!+e2 N3: Pea%"#
%escribe the characteristics that the patient e6hibits that led you to your determination;
Though the patient has e6perienced feelings of depression and an6iety in relation to her health issues, she over all
+peaks with positivity and self!assuredness. +he readily listed her blessings and her thankfulness for the support of her
"hildren. Ghen asked if she feels she has made a positive impact on her environment over her lifetime, she answered
Oes. +he claims having a strong faith has helped her be a positive role model for her family, friends, and former
"olleagues and students. +he claims to lead a small <ible study group at her #A-.
%escribe what impact of disease'condition or hospitalization has had on your patient?s developmental stage of life;
The impact of the patient?s health issues, in addition to her advanced age, has, according to her, lessened her 7uality of
Aife. +he has always prided herself on being independent and a leader in her church community, but now , due to her
%eclining health, she feels less capable of taking care of herself. +he claims this has impacted her self!esteem a bit.
E3 C.$t.a$ A%%e%%'e#t:
Ghat do you think is the causes of your illnessC
The cause of my illness is probably a bit of heredity from my father, along with my poor diet when I was younger.
The fatty foods and salt did not help my high blood pressure and high cholesterol. My heart is reaping what I?ve sown.
Ghat does your illness mean to youC
My illness Just gets in the way of me doing 4od?s work. I can?t be independent anymore. 5art of that is due to my age,
Though, I guess.
E3 SeB.a$!t/ A%%e%%'e#t: (t1e 0"$$"A!#& prompts 'a/ 1e$p t" &.!*e /". *!%,.%%!"#)
Consider beginning with: I am asking about your se!ual history in order to obtain information that will screen for
possible se!ual health problems, these are usually related to either infection, changes with aging and"or quality of life.
#ll of these questions are confidential and protected in your medical record
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3ave you ever been se6ually activeCMMMMMMMMMMOesMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM
%o you prefer women, men or both gendersC MMMMMMMMenMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM
#re you aware of ever having a se6ually transmitted infectionC 5atient denies having any se6ually transmitted infection
3ave you or a partner ever had an abnormal pap smearCMMMMMMM9oMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM
3ave you or your partner received the 4ardasil ,35/0 vaccinationC MMMMMMMMMM9oMMMMMMMMMMMMMMMMMMMMMM

#re you currently se6ually activeC MMMMMMMMM9oMMMMMMMMGhen se6ually active, what measures do you take to
prevent ac7uiring a se6ually transmitted disease or an unintended pregnancyC 5atient did not use condoms or use other
measures
3ow long have you been with your current partnerC Gas married E( years. 5atient does not have current partner.
3ave any medical or surgical conditions changed your ability to have se6ual activityC 9o. 5atient is not se6ually active
%o you have any concerns about se6ual health or how to prevent se6ually transmitted disease or unintended pregnancyC
5atient denies any concerns.
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E3 SMOFING2 CHEMICAL USE2 OCCUPATIONAL/ENVIRONMENTAL EGPOSURES:
*. %oes the patient currently, or has he'she ever smoked or used chewing tobaccoC Oes 9o
If so, whatC 9# 3ow muchC 9# -or how many yearsC
,age thru 0
If applicable, when did the
patient 7uitC
%oes anyone in the patient?s household smoke tobaccoC If
so, what, and how muchC 9o one uses'used tobacco
3as the patient ever tried to 7uitC 9#
(. %oes the patient drink alcohol or has he'she ever drank alcoholC Oes 9o
GhatC Gine 3ow muchC Two glasses with dinner -or how many yearsC
,age (1 thru 1 0
If applicable, when did the patient 7uitC 5atient 7uit drinking about eight years
#go because her children advised that she 7uit drinking all together.
&. 3as the patient ever used street drugs such as mariJuana, cocaine, heroin, or otherC Oes 9o
If so, whatC 9#
3ow muchC 9# -or how many yearsC
,age thru 0
Is the patient currently using these drugsC
Oes 9o
If not, when did he'she 7uitC
9#
2. 3ave you ever, or are you currently e6posed to any occupational or environmental 3azards'.isks
5atient denies ever being e6posed to occupational or environmental hazards and risks.
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(4 REVIE9 OF SYSTEMS
Ge#ea$ C"#%t!t.t!"# Ga%t"!#te%t!#a$ I''.#"$"&!,
.ecent weight loss or gain H 9ausea, vomiting, or diarrhea "hills with severe shaking
I#te&.'e#ta/ H "onstipation Irritable <owel 9ight sweats
"hanges in appearance of skin 4$.% "holecystitis -ever
5roblems with nails Indigestion 4astritis ' 8lcers 3I/ or #I%+
%andruff 3emorrhoids <lood in the stool Aupus
5soriasis Oellow Jaundice 3epatitis .heumatoid #rthritis
3ives or rashes 5ancreatitis +arcoidosis
+kin infections "olitis Tumor
8se of sunscreen +5-; 9o
sunscreen used
%iverticulitis Aife threatening allergic reaction
<athing routine; @nce daily with
assistance
#ppendicitis $nlarged lymph nodes
@ther; #bdominal #bscess @ther;
Aast colonoscopyC 5atient denies
having one.
HEENT @ther; He'at"$"&!,/O#,"$"&!,
H%ifficulty seeing Ge#!t".!#a/ #nemia
"ataracts or 4laucoma nocturia <leeds easily
%ifficulty hearing dysuria <ruises easily
$ar infections hematuria "ancer
+inus pain or infections polyuria <lood Transfusions
9ose bleeds kidney stones <lood type if known; < positive
5ost!nasal drip 9ormal fre7uency of urination; 2 6'day @ther;
@ral'pharyngeal infection <ladder or kidney infections
%ental problems Meta6"$!,/E#*",!#e
H .outine brushing of teeth ( 6'day %iabetes Type;
H .outine dentist visits * 6'year 3ypothyroid '3yperthyroid
/ision screening Intolerance to hot or cold
@ther; @steoporosis
@ther;
P.$'"#a/
%ifficulty <reathing Ce#ta$ Ne+".% S/%te'
"ough ! dry or productive 9OMEN ONLY H "/#
#sthma Infection of the female genitalia H %izziness
<ronchitis Monthly self breast e6am +evere 3eadaches
$mphysema H -re7uency of pap'pelvic e6am Migraines
5neumonia %ate of last gyn e6amC (111 +eizures
Tuberculosis menstrual cycle regular irregular Ticks or Tremors
$nvironmental allergies H menarche ageC *& $ncephalitis
H last "H.C &'(D H menopause ageC E1 Meningitis
@ther;
%ate of last Mammogram N.esult;
%oesn?t know either
@ther;
%ate of %$H# <one %ensity N .esult;
Ca*!"+a%,.$a MEN ONLY Me#ta$ I$$#e%%
H 3ypertension Infection of male genitalia'prostateC %epression
H 3yperlipidemia -re7uency of prostate e6amC +chizophrenia
H "hest pain ' #ngina %ate of last prostate e6amC #n6iety
Myocardial Infarction <53 <ipolar
"#%'5/% 8rinary .etention @ther;
"3- M.%,.$"%@e$eta$
Murmur InJuries or -ractures C1!$*1""* D!%ea%e%
Thrombus H Geakness Measles
.heumatic -ever 5ain Mumps
Myocarditis 4out 5olio
H #rrhythmias @steomyelitis +carlet -ever
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( *1
H Aast $F4 screening, whenC &'() #rthritis H "hicken 5o6
@ther; @ther; @ther;
REVIE9 OF SYSTEMS NARRATIVE
Ge#ea$ C"#%t!t.t!"#
5t?s perception of health; The patient states that her overall health is deteriorated, due to both her advanced age, and her
"ardiovascular problems. +he currently takes aspirin and 5lavi6 on a routine basis. The side effects of these
Medications are 4I!related. +he claims this is most likely why she suffers fre7uent nausea, vomiting, and
"onstipation. The patient claims to do her best to maintain as much autonomy over her health and hygiene as
possible. +he bathes and brushes her teeth daily, and utilizes her health insurance to make yearly dental visits. The
5atient claims her difficulty seeing can be attributed to her old age. +he currently wears reading glasses, but up
8ntil &1 years ago, never needed corrective lenses. The patient also blames her generalized muscle weakness on age,
#lso stating that it may be attributed to her limited mobility. 3er cardiovascular problems have taken the
4reatest toll on her overall health and 7uality of life. 3er hypertension and hyperlipidemia have forced her to
<e ordered onto a cardiac diet. 3er pain and weakness have precipitated her need for bed rest most of the day,
#nd assistance to ambulate. +he feels like she needs to be constantly monitored and aided.
Is there any problem that is not mentioned that your patient sought medical attention for with anyoneC
5atient denies seeking medical attention for any problem not mentioned above.
#ny other 7uestions or comments that your patient would like you to knowC
5atient denies having any other 7uestions or comments concerning her condition.
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( **
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( *(
H(4 PHYSICAL EGAMINATION:
@rientation and level of "onsciousness; #@ 6 &
4eneral +urvey; 3eight; E?( Geight; *21 <MI; &1 5ain; ,include rating N location0
5atient denies any pain during
this e6am
5ulse; D <lood
5ressure; *)*'D* ,. arm0
,include location0
Temperature; ,route takenC0
=D. ,orally0
.espirations;*)
+p@( =2 Is the patient on .oom #ir or @(; .oom #ir
@verall #ppearance; P%ress'grooming'physical handicaps'eye contactQ
H clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
@verall <ehavior; Pe.g.; appropriate'restless'odd mannerisms'agitated'lethargic'otherQ
H awake, calm, rela6ed, interacts well with others, Judgment intact
+peech; Pe.g.; clear'mumbles 'rapid 'slurred'silent'otherQ
H clear, crisp diction
Mood and #ffect; H pleasant H cooperative cheerful talkative H 7uiet boisterous flat
apathetic bizarre agitated an6ious tearful withdrawn aggressive hostile loud
@ther;
I#te&.'e#ta/
H +kin is warm, dry, and intact
H +kin turgor elastic
H 9o rashes, lesions, or deformities
H 9ails without clubbing
H "apillary refill R & seconds
H 3air evenly distributed, clean, without vermin
H 5eripheral I/ site Type; 5/"' 5I/ Aocation; A forearm %ate inserted; &'()'*&
H no redness, edema, or discharge
-luids infusingC no H yes ! whatC 9ormal +aline
5eripheral I/ site Type; Aocation; %ate inserted;
no redness, edema, or discharge
-luids infusingC no yes ! whatC
"entral access device Type; Aocation; %ate inserted;
-luids infusingC no yes ! whatC
HEENT: H -acial features symmetric H9o pain in sinus region H 9o pain, clicking of TM> HTrachea midline
HThyroid not enlarged H 9o palpable lymph nodes Hsclera white and conJunctiva clearB without discharge
H $yebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
-unctional vision; right eye : (1'21 left eye : (1'&E H without corrective lenses right eye ! left eye ! with corrective lenses
-unctional vision both eyes together; H with corrective lenses or 9#
H 5$..A# pupil size (.1 mm H 5eripheral vision intact H$@M intact through ) cardinal fields without nystagmus
H$ars symmetric without lesions or discharge H Ghisper test heard; right ear! ) inches N left ear! ) inches
HGeber test, heard e7ually both ears .inne test, air ( time,s0 longer than bone
H 9ose without lesions or discharge H Aips, buccal mucosa, floor of mouth, N tongue pink N moist without lesions
%entition; 5atient has own teeth, no dentures. @verall good oral hygiene and condition. Teeth white and intact
"omments;
8niversity of +outh -lorida "ollege of 9ursing : .evision #pril (1*( *&
P.$'"#a//T1"aB: H .espirations regular and unlabored HTransverse to #5 ratio (;* H"hest e6pansion symmetric
HAungs clear to auscultation in all fields without adventitious sounds
"A : "lear
H5ercussion resonant throughout all lung fields, dull towards posterior bases
G3 : Gheezes
HTactile fremitus bilaterally e7ual without overt vibration
". ! "rackles
+putum production; thick thin #mount; scant small moderate large
.3 : .honchi
"olor; white pale yellow yellow dark yellow green gray light tan brown red
% : %iminished
9o sputum production is present
+ : +tridor
#b ! #bsent
Ca*!"+a%,.$a: H 9o lifts, heaves, or thrills 5MI felt at; E
th
I"+ Aeft Mid!clavicular line
3eart sounds; +* +( .egular Irregular H9o murmurs, clicks, or adventitious heart sounds H9o >/%
.hythm ,for patients with $"4 tracing : tape ) second strip below and analyze0
Tele strip has been obtained and turned into clinical instructor.
H "alf pain bilaterally negative H5ulses bilaterally e7ual Prating scale; 1!absent, *!barely palpable, (!weak, &!normal, 2!boundingQ
#pical pulse; & "arotid; & <rachial;& .adial; & -emoral; & 5opliteal; & %5; & 5T;&
H9o temporal or carotid bruits $dema; 1 Prating scale; 1!none, S* ,*!(mm0, S( ,&!2mm0, S& ,E!)mm0, S2,D!mm0 Q
Aocation of edema; 9one present pitting non!pitting
H$6tremities warm with capillary refill less than & seconds
GI/GU: H<owel sounds active 6 2 7uadrantsB no bruits auscultated H9o organomegaly Aiver span D cm
H5ercussion dull over liver and spleen and tympanic over stomach and intestine H#bdomen non!tender to palpation
8rine output; H"lear "loudy "olor; Aight yellow 5revious (2 hour output; *,&11 mAs 9'#
-oley "atheter 8rinal or <edpan H<athroom 5rivileges without assistance or with assistance
H "/# punch without rebound tenderness 9one noted this e6am
Aast <M; ,date & ' ( ' *& 0 -ormed +emi!formed 8nformed +oft 3ard Ai7uid Gatery
"olor; Aight brown Medium <rown %ark <rown Oellow 4reen Ghite "offee 4round Maroon <right .ed
3emoccult positive ' negative 9o hemoccult test performed
4enitalia; "lean, moist, without discharge, lesions or odor H9ot assessed, patient alert, oriented, denies problems
@ther : %escribe;
M.%,.$"%@e$eta$: H -ull .@M intact in all e6tremities without crepitus
H +trength bilaterally e7ual at MM2MM in 8$ N MMM2MM in A$
Prating scale; 1!absent, *!trace, (!not against gravity, &!against gravity but not against resistance, 2!against some resistance, E!against full resistanceQ
Hvertebral column without kyphosis or scoliosis
H9eurovascular status intact; peripheral pulses palpable, no pain, pallor, paralysis or parathesias
Ne."$"&!,a$: H5atient awake, alert, oriented to person, place, time, and date "onfusedB if confused attach mini mental e6am
H"9 (!*( grossly intact H +ensation intact to touch, pain, and vibration H.omberg?s 9egative
H+tereognosis, graphesthesia, and proprioception intact H4ait smooth, regular with symmetric length of the stride ,with
assistance0
%T.; Prating scale; 1!absent, S* sluggish'diminished, S( active'e6pected, S& slightly hyperactive, S2 3yperactive, with intermittent or transient clonusQ
Triceps; ( <iceps; ( <rachioradial; ( 5atellar; ( #chilles; ( #nkle clonus; positive negative <abinski; positive negative
H(4 PERTINENT LA: VALUES AND DIAGNOSTIC TEST RESULTS ,include pertinent normals as well as
abnormals, include rationale and analysis. Aist dates with all labs and diagnostic tests0;
3/2I: G<" ).2 3/2;: ).= Ra#&e%: 2.E!**.1 Te#*: +light increase
3gb *(.1 **.D ,A0 *(.1!*).1 %ropped below therapeutic range
5T ** ** *1!*( +tayed the same
I9. (.1 (.E (.1!&.1 +tayed within therapeutic range
9a *2& *21 *&E!*2E +tayed within therapeutic range
F 2.2 2.1 &.E!E +tayed within therapeutic range
<89 && ,30 (= ,30 )!() %ropped but remained high
"r *.1= *.1 1.)!*.& +tayed within therapeutic range
Troponin 1.1) ,9egative0 9ot reassessed 1.11!1.1) 9ot able to note trend
<95 &*E.& ,30 9ot reassessed 1.1!*11.1 9ot able to note trend
D!a&#"%t!,: "H. &'(), $F4 &'() and &'(D, T$$ &'(
A#a$/%!%: The patient?s G<" levels showed a slight increase, but stayed well within normal range. This lab was
Aikely drawn to monitor the patient?s risk for stroke and MI. Troponin and <95 labs are drawn to assess
Ghether the patient has had an +T$MI, or is suffering heart failure, respectively. The <95 level is dangerously
3igh, which is indicative of some heart failure in the patient. Ghy it was not reassessed is unclear. 5T'I9. levels
#re drawn when a patient is on Garfarin or "oumadin therapy, and is a good determinant of bleeding risk. This
5atient is no longer on "oumadin, but is on an aspirin and statin regimen. These values should be fre7uently
#ssessed. 9a and F levels are associated with heart function and rhythm. 3igh F levels are especially indicative
of arrhythmias. These levels remained within therapeutic range. <89 and "reatinine were likely assessed
because the use of #+# can potentiate high levels of these values, which puts the patient at risk for altered renal
function. The <89 level remained high, despite dropping four points. # chest 6!ray revealed cardiomegaly,
which is likely a result of #/ blockage. The $F4 confirmed atrial flutter with variable #/ block. The T$$
,ultrasound0 helped confirm the atrial fibrillation with rapid ventricular rate.
Va# Lee.Ae#2 A.2 V""'e#8D.#!#&2 M.2P"e$1.!%2 D. (24((2 3a#.a/ 2<) 5C"'p$ete :$""* C".#t72 Da+!%J% La6 a#*
D!a&#"%t!, Te%t%2 N.%!#& Ce#ta$. Ret!e+e* 0"':
1ttp://#.%!#&..#6".#*'e*!,!#e.,"'/#.%!#&,e#ta$/.6/+!eA/Da+!%8La68a#*8D!a&#"%t!,8
Te%t%/<2-4-2/a$$/C"'p$ete=:$""*=C".#t=?>CMCV
E2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
The patient is scheduled this afternoon for a catheter ablation procedure, in an attempt to freeze the spot of
Irritability in the heart and correct the atrial flutter. To prepare for this procedure, the patient has been removed
-rom anticoagulation medications apart from aspirin, taken last night with dinner. Today the patient remains
95@. %uring the patient?s hospital stay, she has been ordered on a cardiac diet, and will be visited by a
%ietary consult.
2 Me*!,a$ D!a&#"%e%
,as listed on the chart0
K N.%!#& D!a&#"%e%
(actual and potential ! listed in order of priority0
*. # -ib with ./. greater than *(1 *. #t risk for venous thromboembolus related to immobility
#nd associated dizziness, secondary to atrial fibrillation
#nd tachycardia
(. 3yperlipidemia (. #t risk for bleeds, secondary to aspirin and statin therapy
&. 3ypertension &. #t risk for impaired skin integrity related to lack of
mobility
2. 2. #t risk for falls related to lack of mobility and muscle
Gasting, evidenced by syncopal spells
E. E.
H (- 0" Cae P$a#
N.%!#& D!a&#"%!%: #t risk for venous thromboembolus related to immobility and associated dizziness, secondary to # -ib and tachycardia.
Pat!e#t G"a$%/O.t,"'e% N.%!#& I#te+e#t!"#% t"
A,1!e+e G"a$
Rat!"#a$e 0" I#te+e#t!"#%
P"+!*e Re0ee#,e%
E+a$.at!"# "0 I#te+e#t!"#%
"# Da/ ,ae !% P"+!*e*
9o clots this shift -re7uently assess for altered These are the signs of possible 9o clots or altered tissue perfusion
Mental status, breathing changes, +troke or /T$. 9oted. 5atient e6hibited sound
3eart rate alterations Mental staus, breathing, and
3eart rate. 5atient was able to
$mploy +"%?s to bilateral lower Ghile patient is immobile, these #mbulate around the room with
e6tremities %evices stimulate blood return # nurse to assist.
#ssist patient to ambulate around This will also help circulation, thus
.oom twice daily Aowering the risk of blood pools
In the lower e6tremities
H D!%,1a&e P$a##!#&: ,put a T in front of any pt education in above care plan that you would include for discharge teaching0
C"#%!*e t1e 0"$$"A!#& #ee*%:
U++ "onsult
U%ietary "onsult
H 5T' @T
U5astoral "are
U%urable Medical 9eeds
U-'8 appts
UMed Instruction'5rescription
U are any of the patient?s medications available at a discount pharmacyC UOes U 9o
U.ehab' 33
H 5alliative "are
H (- 0" Cae P$a#
N.%!#& D!a&#"%!%: #t risk for bleeds secondary to anticoagulant therapy
Pat!e#t G"a$%/O.t,"'e% N.%!#& I#te+e#t!"#% t"
A,1!e+e G"a$
Rat!"#a$e 0" I#te+e#t!"#%
P"+!*e Re0ee#,e%
E+a$.at!"# "0 I#te+e#t!"#%
"# Da/ ,ae !% P"+!*e*
Minimize bleeding risk this shift #ssist patient to bathroom and to This will minimize risk for falls <oth goals accomplished.
ambulate That can result in bruising and 9o bleeds were noted this shift,
5atient will verbalize <reaking of the skin. #nd patient verbalized
8nderstanding of hygiene and -re7uently assess patient for warm 8nderstanding of the information
@ther safe practices to prevent #reas, such as lower back and <lood pools are indicative of In the pamphlet. +he also voiced
bleeding Aower e6tremities. #lso, e6amine Internal bleeding and are assessed "onsent to take e6tra care when
+kin and mucus membranes for Through the skin as warm areas. Trimming nails and brushing teeth.
"uts and abrasions
4ive pamphlets regarding safe The patient can take these home
-ootcare, use of soft bristle tooth -or a visual reminder
<rush, and other safe hygiene
practices
H D!%,1a&e P$a##!#&: ,put a T in front of any pt education in above care plan that you would include for discharge teaching0
C"#%!*e t1e 0"$$"A!#& #ee*%:
U++ "onsult
U%ietary "onsult
U5T' @T
U5astoral "are
H%urable Medical 9eeds
U-'8 appts
UMed Instruction'5rescription
U are any of the patient?s medications available at a discount pharmacyC UOes U 9o
U.ehab' 33
H5alliative "are
H (- 0" Cae P$a#
N.%!#& D!a&#"%!%:
Pat!e#t G"a$%/O.t,"'e% N.%!#& I#te+e#t!"#% t"
A,1!e+e G"a$
Rat!"#a$e 0" I#te+e#t!"#%
P"+!*e Re0ee#,e%
E+a$.at!"# "0 I#te+e#t!"#%
"# Da/ ,ae !% P"+!*e*
H D!%,1a&e P$a##!#&: ,put a T in front of any pt education in above care plan that you would include for discharge teaching0
C"#%!*e t1e 0"$$"A!#& #ee*%:
U++ "onsult
U%ietary "onsult
U5T' @T
U5astoral "are
U%urable Medical 9eeds
U-'8 appts
UMed Instruction'5rescription
U are any of the patient?s medications available at a discount pharmacyC UOes U 9o
U.ehab' 33
U5alliative "are
H (- 0" Cae P$a#
N.%!#& D!a&#"%!%:
Pat!e#t G"a$%/O.t,"'e% N.%!#& I#te+e#t!"#% t"
A,1!e+e G"a$
Rat!"#a$e 0" I#te+e#t!"#%
P"+!*e Re0ee#,e%
E+a$.at!"# "0 I#te+e#t!"#%
"# Da/ ,ae !% P"+!*e*
H D!%,1a&e P$a##!#&: ,put a T in front of any pt education in above care plan that you would include for discharge teaching0
C"#%!*e t1e 0"$$"A!#& #ee*%:
U++ "onsult
U%ietary "onsult
U5T' @T
U5astoral "are
U%urable Medical 9eeds
U-'8 appts
UMed Instruction'5rescription
U are any of the patient?s medications available at a discount pharmacyC UOes U 9o
U.ehab' 33
U5alliative "are