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UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Krista Caprio
MSI & MSII PATIENT ASSESSMENT TOOL .
1 PATIENT INFORMATION
Patient Initials: L.D.
Age: 52
Gender: Female

Marital Status: Divorced

Assignment Date: 9/18/15

Agency: Sarasota Memorial


Hospital
Admission Date: 9/17/15
Primary Medical Diagnosis: Hypertensive
urgency

Primary Language: English


Level of Education: High school, attended 2 semesters of
college

Other Medical Diagnoses: No new medical


diagnosis in this admission

Occupation (if retired, what from?): Unemployed


Number/ages children/siblings: No children, three sisters
ages 50, 48, and 43
Served/Veteran: No

Code Status: Full code

Living Arrangements: Staying with a friend

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: No surgeries
Procedure: No procedures

Culture/ Ethnicity /Nationality: English, Caucasian


Religion: Does not practice a religion

Type of Insurance: No insurance

1 CHIEF COMPLAINT: I have fainting episodes all the time, but the other day was the worst it has ever
been. I passed out completely while paying for gas. I lost consciousness and hit my head. I was brought into the
hospital by an ambulance.
3 HISTORY OF PRESENT ILLNESS:
The patient has had fainting spells for about 6 months. She said that sometimes she can feel them coming,
because she gets nauseous, therefore she lies down and the feeling goes away. She stated that she is scared
because she does not know what is causing them, and she has had to change her life around for the past 6
months to try and work around the fainting spells. She stated that they could happen when shes doing activities
such as driving, but they also occur when she is just sitting doing nothing. Recently she had an episode that she
claims is the worst it has ever been. She completely lost consciousness and only remembers paying the cashier
for gas and then waking up in the hospital. The patient was hypertensive upon arriving to the hospital and was
projectile vomiting. She stated that this has never happened to her before. The patient was admitted through the
emergency department on 9/17. Since then she has gone through many tests such as a head CT, cervical spine
CT, EKG, and an ECHO. These test were ordered in order to rule out any head trauma from her fall as well as
University of South Florida College of Nursing Revision September 2014

try to find a reason for why these fainting spells are happening. So far, all tests have been negative and the
patient will be discharged in the next day or so.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
Date

Operation or Illness

1980

Car accident that resulted in a head injury. The patients states she does not know what type
of head injury occurred
Tonsils removed
4 Laparoscopies due to endometriosis

1968
Dates are
unknown to the
patient
2003

Hysterectomy

Father

75

Mother

74

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Arthritis

Anemia

Cause
of
Death
(if
applicable
)
Sepsis

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Hypertension, Patient is taking Metoprolol 50mg by mouth (PO) twice daily and Enalapril 20mg PO
once daily

Age (in years)

2008

Brother
Sister
Sister

48

Sister

50

45

relationship

Comments: Patient

states she does not know age of onset for her familys diseases. She denies any other family
illnesses. The patient was diagnosed with hypertension in 2008; she is on medication though it is not controlled .

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria
Adult Tetanus
Influenza (flu)

YES

University of South Florida College of Nursing Revision September 2014

NO

Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction

Clindamycin
Lortab

Patient states she gets swollen and hives


GI distress such as nausea and diarrhea

Tape
Latex

Hives where the tape was placed


Itching red rash

Medications

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)
Hypertension is a chronic elevation in blood pressure. Two factors can affect blood pressure: cardiac output and
systemic vascular resistance. Patients with high blood pressure may have an increased cardiac output, an
increased resistance, or both. Usually in older adults, the reason for high blood pressure is the stiffening of the
vasculature such as stiffening of the aorta which will increase pressure. There are many risk factors for
hypertension, some modifiable and some not. For example, older age, male gender, African Americans,
smokers, diabetics, having a family history, being obese/over -weight, excessive sodium in your diet, drinking
too much alcohol, stress, and living a sedentary lifestyle are just some of them. People are diagnosed with stage
1 hypertension when their systolic blood pressure is from 140-159 and their diastolic is 90-99. In order to be
diagnosed, there has to be at least 2 or more high blood pressure readings at several doctors appointments.
Antihypertensive medications can be given to control hypertension, some examples are, beta-blockers, ACE
inhibitors, angiotensin2 receptor agonists, calcium channel blockers, direct vasodilators, and thiazide diuretics.
All antihypertensive drugs work by either decreasing cardiac output, decreasing the peripheral vascular
resistance, or both. The first treatment to managing hypertension is life-style modification. This includes
decreasing sodium in the diet, losing weight, increasing exercise, controlling diabetes, and cessation of
smoking. Medications are used when the modifications have not been successful. Prognosis for people with
hypertension is good if it is controlled with lifestyle changes and medications. Hypertension is a leading risk
factor for coronary artery disease. If hypertension is not managed properly, clients diagnosed with hypertension
are at a huge risk for heart attack and stroke. Long- term uncontrolled hypertension is also damaging to the
organs such as the kidneys and can lead to renal disease/ kidney failure (Foex & Sear, 2004).
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation), routine, and PRN
medication . Give trade and generic name.] (Nursing Central from Unbound Medicine)
Name: metoprolol (Lopresor)
Concentration: 50mg
Dosage Amount: 50mg
Route: By mouth (PO)
Frequency: Twice a day
Pharmaceutical class: Antihypertensive
Home
Hospital
or
Both
Indication: Treatment of hypertension
University of South Florida College of Nursing Revision September 2014

Adverse/ Side effects: Fatigue, weakness, anxiety, depression, dizziness, bradycardia, hypotension, pulmonary
edema, rashes, constipation, diarrhea, nausea/vomiting,
Nursing considerations/ Patient Teaching: Take medication as directed, abrupt withdrawal can cause lifethreatening arrhythmias, hypertension, or myocardial infarction. Check pulses and blood pressure daily. May
cause drowsiness avoid activities such as driving until response to drug is known. Notify provider is slow pulse,
difficulty breathing, dizziness, rash.
Name: enalapril (Vasotec)
Concentration: 20mg
Dosage Amount: 20mg
Route: PO
Frequency: Once daily
Pharmaceutical class: Antihypertensive
Home
Hospital
or
Both
Indication: Alone or with other agents in the management of hypertension
Adverse/ Side effects: Dizziness, fatigue, headache, weakness, hypotension, diarrhea, nausea/vomiting, dyspnea,
hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Take medication as directed, avoid salt substitutes containing
potassium, change positions slowly, avoid driving and other activities requiring alertness until response is known,
notify provider of rash, sore throat, fever, irregular heartbeat, swelling of the face, dry cough may occur until
medication is discontinued, monitor blood pressure
Name: enoxaparin (Lovenox)
Concentration: 40mg
Dosage Amount: 40mg
Route: Subcutaneous
Frequency: Once daily
Pharmaceutical class: antithrombotics
Home
Hospital
or
Both
Indication: Prevention of DVT, VTE, or PE
Side effects/Nursing considerations: Dizziness, headache, insomnia, hyperkalemia, fever, bleeding, edema,
report any symptoms of unusual bleeding or bruising, not to take with aspirin or ibuprofen without consulting a
healthcare professional
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
When looking at the nutrition report my patient was

under the recommended target for almost everything.


In a recommended 2000-calorie diet, she was only at
904. This means that she is not getting an adequate
amount of protein carbohydrates and fat each day. I
would recommend not skipping breakfast because it is
an important meal to start off the day. In addition,
including breakfast would increase her daily calories
and bring her closer to meeting the recommended
macronutrient levels. Because my patient has
hypertension she should maintain a lower saturated fat
intake. Less than 10% of the daily intake is
recommended. My patients average was only 3% so
that is good. Also she should have a decreased sodium
intake due to her hypertension (less than 1500mg a
day) hers came in at 1532mg a day which is not too
bad. She could decrease it by eating rice with a lower
sodium content (buying canned items that say reduced
sodium, low sodium, or no salt added). My patient was
also falling short in all of her major food groups. If she
included breakfast for example, fruit and a turkey and
University of South Florida College of Nursing Revision September 2014

low fat cheese sandwich on wheat bread for lunch she


would be able to increase that area as well.
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: Pt states she doesnt usually have breakfast
Lunch: 1 Banana and 8oz container of low fat vanilla
yogurt
Dinner: 1 medium Chicken breast- baked, no skin, 1 cup
canned black beans and 1 cup white rice
Snacks: Pt doesnt usually have snacks
Liquids (include alcohol): Pt says she usually has water
or 1 cup Gatorade
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? Patient states that she has some friends and he ex-husband that usually help

her when she is ill.


How do you generally cope with stress? or What do you do when you are upset? The patient stated that
when she is stressed she will usually cry or walk her dog which helps to relive the stress.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
She stated that she is under some stress because she just received notice that she is going to be evicted from her
house. As of right now, she doesnt have a place to live so she is hoping between friends and sleeping in her car.
+2 DOMESTIC VIOLENCE ASSESSMENT

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
Are you currently in a safe relationship? Patient states that she is currently not in a relationship, but she does
feel safe staying with her friends.

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development: Trust vs.

Mistrust

Autonomy vs.

University of South Florida College of Nursing Revision September 2014

Doubt & Shame


5

Initiative vs. Guilt


Industry vs. Inferiority
Identity vs.
vs. Isolation
Generativity vs. Self absorption/Stagnation

Role Confusion/Diffusion
Ego Integrity vs. Despair

Intimacy

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your Patients age group:

Since my patient is 52 years old her category would be the generativity vs. stagnation. In this stage, we usually
establish careers settle down in a relationship and begin families. We give back to society through raising our
kids, being productive at work, and involved in the community. When we fail to achieve these things we
become stagnant and feel unproductive (McLeod, 2013).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:

Through talking with my patient, I concluded that she was in the stagnant developmental stage. I picked this
one, because she is 52 years old, divorced, has no children, and lives by herself. She is also unemployed. The
stage of generativity is when the person gives back and, and my patient has not done this. Im not sure
specifically how long she has been unemployed, but she has been divorced for a long time. She stated that when
she is home she really doesnt do much; she just walks her dog. In my opinion, this is not giving back to society.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

My patient stated that she has been dealing with her condition for about 6 months. For this reason, I dont think
this particular condition has had much of an influence on her developmental stage of life. As stated before the
stagnant phase is when you have not given back to the community through your job, children ect. So, a
condition that started recently should not have affected her to the degree of not having children and no job when
she told me that she has been unemployed and without insurance for a long time.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? The patient indicates that she is not sure what the cause of
her illness is. That is why she is in the hospital.
What does your illness mean to you? The patient stated that her illness means she is sick and she is not sure
why or what to do about it. She is hoping that being in the hospital will help to figure that out and relive some
of her stress.
+3 SEXUALITY ASSESSMENT:
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Men
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? No
Have you or your partner received the Gardasil (HPV) vaccination? No
Are you currently sexually active? No
If yes, are you in a monogamous relationship? N/A
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or
an unintended pregnancy? Condoms
How long have you been with your current partner? The patient is not with a partner
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
1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
The patient states that she was baptized as a child but she does not practice any religion.
University of South Florida College of Nursing Revision September 2014

Do your religious beliefs influence your current condition?


Patient does not believe that her beliefs influence her condition.
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what? Cigarettes
How much?(specify daily amount)
A pack a day

Yes
No
For how many years? 42years
(age 13

thru

52

If applicable, when did the


patient quit? June 2015

Pack Years: 42
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No

Has the patient ever tried to quit? Yes she quit 3 months
ago
If yes, what did they use to try to quit? Quit cold turkey

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
What? Kahlua and sometimes wine
How much? Two drinks
Volume: 350ml
Frequency: Only on holidays
If applicable, when did the patient quit?
N/A

No
For how many years?
(age 13

thru 52

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what? N/A
How much? N/A
For how many years? N/A
Is the patient currently using these
drugs? N/A

If not, when did he/she quit?


N/A

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

10 REVIEW OF SYSTEMS NARRATIVE


Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen Patient does not use
sunscreen
Bathing routine: Twice a day
Other:

HEENT
Difficulty seeing - Glasses
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems- Teeth are breaking
Routine brushing of teeth
2 x/day
Routine dentist visitsSometimes1x/year
Vision screening- 1x/ year
Other:

Immunologic

Nausea, vomiting, or diarrhea


Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis

Chills with severe shaking


Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor

Diverticulitis

Life threatening allergic reaction

Appendicitis
Abdominal Abscess
Last colonoscopy? N/A
Other:

Enlarged lymph nodes


Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 6 x/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
Diabetes

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 9/17/15- negative findings
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus

Central Nervous System


WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? Unknown to
patient
menstrual cycle N/A
menarche
menopause Hysterectomy 2003
Date of last Mammogram &Result: 5/15,
Negative
Date of DEXA Bone Density & Result:
N/A
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other: Syncopal episodes

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness

Childhood Diseases
Measles

University of South Florida College of Nursing Revision September 2014

Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 9/17/15,
negative findings
Other:

Pain
Gout
Osteomyelitis

Mumps
Polio
Scarlet Fever

Arthritis

Chicken Pox

Other:

Other:

General Constitution
Recent weight loss or gain
How many lbs? 125105
Time frame? A couple weeks, due to unknown cause
Intentional?
How do you view your overall health? Patient states that besides her fainting spells she believes she is in pretty good 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

10 PHYSICAL EXAMINATION:
General Survey: This
Height: 61.5in
Weight: 113lbs
BMI: 21.09
Pain: No pain
patient is an alert and
Pulse: 72 BPM
Blood Pressure:149/101 Left upper
oriented, very pleasant,
arm
Respirations: 18
but anxious 52 year old
women. She becomes
stressed when she talks
about her illness because
she does not know what
is causing it; however,
she is cooperative and
likes to talk.
Temperature: 98.4
SpO2: 100
Is the patient on Room Air or O2:
degrees Fahrenheit, oral
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
Central access device: N/A Type: 20g peripheral IV
Location: Right hand
Date inserted: 9/17/15
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
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: equal distance on right and left sides
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Patients teeth are yellow; she states she has not been to the dentist in a while. Her teeth are chipping.
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
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

Chest expansion

University of South Florida College of Nursing Revision September 2014

10

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

Calf pain bilaterally negative


Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3
Carotid: 3
Brachial: 3
Radial:
3
Femoral: 2
Popliteal: 2
DP: 2
PT: 2
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
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: 9/18/15
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
Other Describe:
GU
Urine output:
Clear
Cloudy
Color:
Foley Catheter
Urinal or Bedpan
Bathroom Privileges
CVA punch without rebound tenderness

Not assessed, patient alert, oriented, denies problems


Previous 24 hour output: N/A
without assistance

or

with assistance

Musculoskeletal: Full ROM intact in all extremities without crepitus


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]

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: 2

Biceps: 2

Brachioradial:

Patellar: 2

Achilles: 2

Ankle clonus: positive negative Babinski: positive

negative

University of South Florida College of Nursing Revision September 2014

11

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):

Lab
Troponins

Dates
9/17

Head CT

9/17

Trend
Each of these lab tests
were done one time. They
were used to figure out
why the patient is fainting
randomly. In addition, if
there was any trauma
after her fall. For all of
these tests the results
were negative. There
were no significant
findings that showed a
possible solution to why
she was having these
episodes.

Analysis
The patients troponin
levels were 0. These were
ordered with the purpose
of seeing if there was any
sort of damage to the
heart for example, a
myocardial infarction that
could have been the
reason for her lightheadedness and fainting.
Troponin levels would be
increased if there was any
damage to the heart.

This patient hit her head


when she went
unconscious. This test
was done to see if there
was any damage done to
her head when she fell
such as a bleed,
increasing cerebral spinal
fluid, swelling, or
anything else that could
cause increased
intracranial pressure.
Cervical Spine CT
9/17
As stated before the
patient fell. This test was
also done to see if there
was any damage done to
her cervical spine after
the fall such as a fracture.
All results were negative.
EKG
9/17
The EKG was done in
order to see if she has any
abnormal heart rhythms
such as A-fib which could
lead to her brain and body
not getting enough O2
thus leading to a syncopal
episode. Also this test
could show signs of a
myocardial infarction. All
University of South Florida College of Nursing Revision September 2014
12

ECHO

9/17

results were negative


Lastly an ECHO was
done. This visualizes the
heart and how it is
pumping. A possible
explanation for her
fainting was the lack of
blood being pumped into
her brain. Though the
ECHO showed all normal
findings. Her Ejection
fraction was 65%

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:


This patient had full bathroom privileges without assistance. The diagnostic tests and findings that were done for
this patient are stated above. Vitals were taken every 4 hours though we took Orthostatic blood pressures to see if
maybe a change in position and drop in blood pressure could be another cause of her fainting. The results were
negative. Her diet was regular and she was to receive her antihypertensive medications as she is prescribed to
take them at home. This patient is to be discharged home within the next day or so.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Risk for ineffective tissue perfusion related to syncopal episode
2. Risk for falls/injury related to dizziness and syncopal episode
3. Anxiety related to perceived threat to biological integrity as evidence by increased heart rate, hyperventilation, and
verbalization of anxiety.
4. Knowledge deficit related to lack of self- care as evidence by not taking hypertensive medications

University of South Florida College of Nursing Revision September 2014

13

15 CARE PLAN
Nursing Diagnosis: Risk for ineffective tissue perfusion related to syncopal episode
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1.Client will demonstrate adequate 1. Monitor for signs of decreased
Signs of decreased cardiac output
Throughout the shift the patient
perfusion of tissues as evidence by cardiac output; monitor vitals,
such as a low blood pressure high
maintained adequate tissue
adequate vitals within normal
listen to heart and lung sounds,
heart rate, and lack of peripheral
perfusion. Her vitals maintained
parameters for this patient and
monitor labs
pulses are things we need to
within normal parameters specific
stable neuro status by the end of
2. Monitor neuro status every 4
monitor for to ensure the patient is to her. There were no signs of
shift.
hours
getting adequate blood flow to the
decreased cardiac output or change
3. Maintain heart rate under 100
brain and other tissues. A change
in neuro status throughout the shift.
and systolic blood pressure over 90 in neuro status could indicate a
but under 120
lack of blood flow as well as O2 to
the brain and other tissues (Ackley,
2010).
Patient Goals/Outcomes

2. Patient will display no further


deterioration by end of shift.

1. Administer hypertensive
medications as indicated
2. Maintain a quiet relaxed
environment
3. Monitor input and changes in
urine output

3. **Client will know and


understand the symptoms of
ineffective tissue perfusion by time
of discharge

1. Teach client signs of ineffective


tissue perfusion such as a decrease
in amount of urination, increasing
heart rate and lightheadedness
2. Have the patient teach back the
information that was taught to her

Persistent hypertension can cause


further deterioration in the patients
condition, so administering her
medications will help to control
this. If a patient has a change in
urine output this could indicate a
decrease in circulating volume that
can negatively affect the perfusion
of the organs. Maintaining a quiet
environment will help the patient to
relax and decrease anxiety (Ackley,
2010).
Teaching the client symptoms of
ineffective tissue perfusion to
report can get her care faster.
Having her teach back the methods
will ensure she understands the
teaching that was given (Ackley,
2010).

University of South Florida College of Nursing Revision September 2014

Throughout the shift, there was no


evidence of further deterioration.
Hypertensive medications were
given as ordered; patient
maintained an adequate blood
pressure. There were no changes in
urine output from time of
admission throughout the patients
stay. The environment was quiet
and there were no reports of
anxiety after interventions were
implemented.
Goal not met, I was not there
during her time of discharge in
order to determine if the client
understood the teaching that was
given to her.

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2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
Nursing Diagnosis: Risk for fall or injury related to dizziness and syncopal episode
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
1. Client will remain safe from falls 1. Bed will be kept in low position Putting these interventions in place The client did not experience any
throughout shift
at all times with brakes engaged,
will increase the safety of the
falls throughout shift. Precautions
no slip yellow socks will be worn
patient by decreasing her risk of
were put into place and the client
2. Keep needed items within reach, falling. Teaching the client to rise
called for assistance when it was
encourage client to use call bell
slowly will prevent her blood
needed.
when assistance is needed
pressure form dropping quickly
3. Client will be taught to rise
which can lead to dizziness and
slowly and take her time
falling (Ackley, 2010).
2. Client will protect herself from
1. Client will be taught to remain
Teaching the client to stay hydrated The client was taught these
injury due to dizziness throughout
hydrated
will decrease the risk of
interventions and implemented
shift
2. Client will be taught symptoms
dehydration which can lead to
them throughout the shift. The
to report
dizziness/lightheadedness.
client remained in bed while dizzy
3. Client will be taught activities to Teaching the client to report
and stayed hydrated. No worsening
avoid while feeling dizzy
worsening symptoms such as
symptoms occurred.
excessive nausea and vomiting will
help her get treated earlier and
decrease the risk of progressing
symptoms. Lastly, teaching the
client to avoid activities such as
walking while dizzy will decrease
her risk of falling/injury (Ackley,
University of South Florida College of Nursing Revision September 2014
15

**3. Client will be able to explain


methods to prevent injury by time
of discharge

2010).
If the client knows and understands
these practices she will be able to
reduce her risk of injury for when
she is to be discharged home
(Ackley, 2010).

1. Client will be taught ways to


Goal not met, I was not there when
prevent falls due to dizziness for
the patient was to be discharged in
example, sitting down when she
order to determine if teaching was
feels dizzy or nauseous, getting up
understood.
slowly, and stopping the car off to
the side of the road at the first signs
of dizziness
2. Client will be able to teach back
these methods
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appointments
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision September 2014

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References
Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: An evidence-based guide to
planning care. Maryland Heights, MO: Mosby.
ChooseMyPlate.gov. (n.d.). Retrieved from http://www.choosemyplate.gov/
Foex, P., Sear, J. W. (2004) Hypertension: Pathophysiology and treatment. Continuing
Education in Anaesthesia, Crtical Care & Pain, (4)3, 71-75. doi:
10.1093/bjaceaccp/mkh020
McLeod, S. (2013). Erik Erikson. Retrieved from http://www.simplypsychology.org/ErikErikson.html
Nursing Central from Unbound Medicine

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University of South Florida College of Nursing Revision September 2014

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