UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Hope Hindmarch

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 10/04/2015

Agency:Bayfront

Patient Initials: RC

Age: 68

Admission Date: 08/20/2015

Gender: Female

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

I71.4: Abdominal Aortic Aneurysm

Primary Language: English

Level of Education: High School graduate

Other Medical Diagnoses: Coronary Artery

Disease, Hypertension, COPD, venous
insufficiency

Occupation (if retired, what from?): Retired secretary

Number/ages children/siblings: One Son, deceased. One brother,
deceased
Served/Veteran: No

Code Status: Full

Living Arrangements: Lives at home with fianc.

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 9/2 Procedure: Cardiac
Catheterization with stent placement

Culture/ Ethnicity /Nationality: French, Polish, American

Religion: Catholic

Type of Insurance: Medicare

1 CHIEF COMPLAINT: I had extremely painful abdominal pain and I thought it was my appendix

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient began experiencing abdominal pain in early July that she believed was related to constipation. Patient states the
pain became worse two weeks ago. On 8/16/2015 the pain became unbearable and she was taken by EMS to St.
Petersburg General Hospital. Patient states the pain is in the right lower quadrant, she describes the pain as both sharp and
dull. Movement aggravates the pain and Motrin somewhat relieves the pain. When EMS arrived she rated the pain as 10
on a scale of 0 to 10. St. Petersburg Hospital diagnosed her pain as a symptom from bilateral inguinal hernias. Patient
arrived to Bayfront on 08/20/2015 and no evidence of hernias were found. A KUB, chest x ray, and CT were preformed on
8/21 and showed no signs of abdominal or bowel obstruction, however a 5.1cm abdominal aortic aneurysm and COPD
were noted. Upon admission to Bayfront the patient was also found to have hypertension and coronary artery disease. On
9/2/2015 the patient underwent a cardiac catheterization with placement of 6 stents. On 9/4/2015 a CT angiogram of the
neck detected artherosclerosis of the aortic arch and a carotid duplex scan detected 70% stenosis of the left carotid artery
and 50-69% stenosis of the right internal carotid artery. Due to the patients obesity and cardiac state her abdominal aortic
aneurysm will be monitored as an outpatient until it reaches 5.5cm. The patient was also determined to not be a candidate
for an endarterectomy to correct her carotid stenosis at this time. Currently the patient is receiving treatment to control her
hypertension and CAD, and will likely be discharged tomorrow 9/5/2015.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date

Operation or Illness

Father
Mother
Brother

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Hypertension
Problems
Kidney

Gout
Heart Trouble
(angina, MI, DVT etc.)

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Anemia
Arthritis

Cause
of
Death
(if
applicable
)
Liver
60
X
Cirrhosis
Liver
68
X
Cirrhosis
Liver
50
X
Cirrhosis

Environmental
Allergies

2
FAMILY
MEDICAL
HISTORY

Alcoholism

Brain aneurysm resection

Cholecystectomy

Age (in years)

1995
2000

Sister
relationship
relationship
relationship

Comments: Include date of onset

Patient states, I dont know anything. My family kept to themselves

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 (Date)
Adult Tetanus (Date)

YES

University of South Florida College of Nursing Revision August 2013

NO

X
X
X
X

Influenza (flu) (Date)

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

NAME of
Causative Agent

X
X
X

Type of Reaction (describe explicitly)

NKA
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)
An aneurysm occurs when the tunica media of an artery becomes diseased and thinned leading to an outpouching. An
aneurysm can be fusiform, bulging on both sides, or saccular, unilateral bulging. The most common place for an aortic
aneurysm to occur is at the level of the renal arteries- an abdominal aortic aneurysm, or AAA, although they can occur
anywhere in the aorta. Atherosclerosis and degeneration of the tunica media are the most common cause of aortic
aneurysms. In atherosclerosis plaque formation wears away the vessel wall and stimulates the inflammatory process
which further damages the arterial wall. Another cause of aortic aneurysms can be hypertension. Hypertension creates
constant stress on the vessel wall which causes damage to the inner lining of the vessel ( Huether, & McCance, 2012).
Other causes include trauma, congenital abnormalities, and disease. Once the aneurysm begins it will continue to grow
larger as tension from blood flow continues to press upon the weakened vessel wall. If left untreated it will grow until the
point in which it ruptures. Risk factors for developing an aortic aneurysm include being of male gender, aging, smoking,
hypertension, hyperlipidemia, and family history. Abdominal aortic aneurysms are often asymptomatic, but can present as
persistent abdominal pain. Upon physical assessment it may present as a pulsating mass in close proximity to the
umbilicus and upon auscultation a bruit, caused by turbulent blood flow, may be heard over the site. An aortic aneurysm
can be diagnosed by abdominal ultrasound, CT scan, abdominal angiography, and MRA. The diagnostic criteria for an
abdominal aortic aneurysm is an aortic aneurysm greater than 3 centimeters in diameter. Treatment for AAAs include
ultrasounds every six months to monitor growth, blood pressure control, lipid value control, smoking cessation, and
discontinuation of steroids if applicable. Surgical treatment includes open surgical repair and endovascular repair. Surgical
repair is indicated for abdominal aortic aneurysms measuring 5.5 centimeters or more. The risk for rupture is high in
abdominal aortic aneurysms of 5.5 centimeters, and the mortality rate for surgery of a ruptured AAA is 40%. ( Osborn,

Wraa, Watson, & Holleran, 2010).

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN
medication. Give trade and generic name.]
Name: amlodipine (Norvasc)

Concentration (mg/ml)

Dosage Amount (mg) 10MG= 1 TAB

Route: PO
Frequency: Daily
Pharmaceutical class: Calcium Channel Blocker
Home
Hospital X
or
Both
Indication: Hypertension
Side effects/Nursing considerations: dizziness, fatigue, peripheral edema, bradycardia, hypotension, palpitations, angina,
gingival hyperplasia, flushing, and nausea

University of South Florida College of Nursing Revision August 2013

Considerations: Monitor blood pressure before administration, according to order hold for systolic below 110 or diastolic
below 60. Monitor ECG. Monitor for bradycardia
Name: aspirin (ASA, Bayer)

Concentration

Dosage Amount: 325MG= 1 TAB

Route: PO
Frequency: Daily
Pharmaceutical class: Salicylates
Home
Hospital X
or
Both
Indication: Prophylaxis of transient ischemic attacks and MI
Side effects/Nursing considerations: Tinnitis, GI bleeding, dyspepsia, epigastric distress, nausea, abdominal pain, anemia,
hemolysis, rash, uticaria, anaphylaxis, laryngeal edema, hepatotoxicity, vomiting, and anorexia. Considerations: Educate
patient to avoid concurrent use with alcohol, and to report tinnitus, unusual bleeding of the gums, bruising, tarry stool, or
fever lasting more than 3 days.
Name: atorvastatin (Lipitor)

Concentration

Dosage Amount: 10MG= 1 TAB

Route: PO
Frequency: At bedtime (HS)
Pharmaceutical class: hmg coa reductase inhibitors Home
Hospital X
or
Both
Indication: Prevention of coronary heart disease. Adjunctive management of primary hypercholesterolemia and mixed
dyslipidemia
Side effects/Nursing considerations: abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, rashes,
rhabdomyolysis, angioneurotic edema, confusion, peripheral edema, chest pain, hyperglycemia, erectile dysfunction, druginduced hepatitis, and pacreatitis. Considerations: CPK levels should be drawn if patient develops muscle tenderness. Have
patient avoid grapefruit juice. Educate patient to contact provider if muscle pain or weakness occurs, or if they become
pregnant.
Name: clopidogrel (Plavix)
Concentration:
Dosage Amount: 75MG=1TAB
Route: PO
Frequency: Daily
Pharmaceutical class: platelet aggregation inhibitor Home
Hospital X
or
Both
Indication: Reduction of atherosclerotic events
Side effects/Nursing considerations: GI bleeding, drug rash with eosinophilia and systemic symptoms, bleeding,
neutropenia, thrombotic thrombocytopenic purpura, depression, fatigue, epitaxis, cough, dyspmea, edema, hypertension,
abdominal pain, and hypercholesterolemia.
Considerations: Monitor for bleeding. Monitor platelet count and CBC. Educate patient to notify provider of fever, chills,
sore throat, rash, or if unusual bleeding occurs.
Name: docusate-senna (Peri-Colace)

Concentration

Dosage Amount: 50MG= 2TAB

Route: PO
Frequency: 2X Daily
Pharmaceutical class: Stimulant laxative, stool
Home
Hospital X
or
Both
softener
Indication: Treatment of constipation. Prevention of opioid induced constipation.
Side effects/Nursing considerations: Electrolyte imbalances, diarrhea, nausea, abdominal cramps, rash, and urine
discoloration.
Considerations: Hold for loose stools. Educate patient that laxatives should be used for short term treatment of constipation.
Administer with a full glass of water.
Name: Lisinopril

Concentration

Dosage Amount: 10MG=1TAB

Route: PO
Frequency: Daily
Pharmaceutical class: ace inhibitor
Home
Hospital X or
Both
Indication: Management of hypertension
Side effects/Nursing considerations: angioedema, dry cough, dizziness, hypotension, hyperkalemia, erectile dysfunction,
headache, impaired renal function.
Considerations: Assess for signs of angioedema. Monitor blood pressure and pulse. Monitor for hyperkalemia and an
increased BUN.

University of South Florida College of Nursing Revision August 2013

Name: metoprolol (Lopressor)

Concentration

Dosage Amount: 25MG=1TAB

Route: PO
Frequency: 2X Daily
Pharmaceutical class: Beta blocker
Home
Hospital X or
Both
Indication: Hypertension. Prevention of MI.
Side effects/Nursing considerations: bradycardia, heart failure, pulmonary edema, hypotension, fatigue, weakness,
erectile dysfunction, hyperglycemia, blurred vision, bronchospasm, and decreased libido.
Considerations: Hold for heart rate less than 60 or systolic blood pressure less than 90mmHg. Monitor heart rate and blood
pressure. Monitor input and output
Name: pantoprazole (Protonix)

Concentration

Dosage Amount: 40MG= 1TAB

Route: PO
Frequency: Daily
Pharmaceutical class: proton pump inhibitors
Home
Hospital X
or
Both
Indication: Decrease relapse rates of daytime and nighttime symptoms of heartburn
Side effects/Nursing considerations: pseudomembranous colitis, headache, abdominal pain, hyperglycemia,
hypomagnesemia, and bone fracture.
Considerations: Assess for abdominal pain. Monitor bowel movements for signs of pseudomembranous colitis. Educate
patient to report signs of diarrhea, abdominal cramping, bloody stools, and fever.
Name: cefaxolin (Ancef IVPB)

Concentration: 1GM/50ML

Dosage Amount: 1GM, 50 ML

Route: IVPB, 100ml/hr

Frequency:
Pharmaceutical class: first generation cephalosporin Home
Hospital X or
Both
Indication: Perioperative prophylaxis
Side effects/Nursing considerations: Seizures, pseudomembranous colitis, stevens-johnson syndrome, rash, diarrhea,
nausea, vomiting, pruritis, leukopenia, phlebitis at IV site, and allergic reactions.
Considerations: Monitor for signs of anaphylaxis. Monitor bowel function for signs of diarrhea. Assess skin frequently for
rashes, discontinue at first sign of rash.
Name: acetaminophen-Hydrocodone
Concentration
Dosage Amount: 1 TAB
(Vicodin)
Route: PO
Frequency: Q4hr, PRN for pain scale 7-10, severe pain
Pharmaceutical class: opioid agonists nonopioid
Home
Hospital X or
Both
analgesic combinations
Indication: Management of severe pain
Side effects/Nursing considerations: confusion, dizziness, sedation, euphoria, hypotension, dyspepsia, constipation,
urinary retention, physical dependence, psychological dependence, and sweating.
Considerations: Do not use within 14 days of a MAOI. Assess respirations, blood pressure, and pulse frequently. Monitor
bowel function for signs of constipation. Naloxone is the antidote.

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Cardiac
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? None
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patient does not follow any sort of diet at home.
According to her diet recall she is eating too many refined
grains. She should consider reducing her grain intake and
switching refined grains for whole grains that will keep her
satisfied longer. The patient does not eat enough vegetables
or protein and should consider adding a vegetable side to
her lunch and dinner. She could also switch from bread to
eggs for her first meal of the day to reduce her refined grain
intake and increase her protein. The patient is consuming
over twice the recommended amount of saturated fat. Since
this patient suffers from coronary artery disease she must
decrease the amount of fat she is consuming to reduce her
risk of further complications. Some ways she can
accomplish this is by switching from ground beef, that is
high in fat, for dinner to a piece of lean chicken or fish, and
to greatly reduce the amount of cheese she consumes. The
patient is also consuming twice the recommended amount
of sodium. Due to her cardiac condition she needs to
restrict the amount of sodium she is eating in order to help
reduce her blood pressure. The patient should reduce her
sodium intake to 2 grams. She can do this by decreasing the
amount of cheese she eats and by switching to low sodium
snacks (Supertracker: My foods. My fitness. My health).
Breakfast: No breakfast
Lunch: 3 Pieces of Cinnamon toast with a tablespoon of
butter
Dinner: 1 Cheeseburger with a slice of sharp cheddar, mild
cheddar, mozzarella, onion, and chili sauce.
Snacks: 1 cup of pretzels. 1 cups of vanilla ice cream
with 5 tablespoons of cool whip and 3 tablespoons of
chocolate sauce.
Liquids (include alcohol): 3 cups of coffee with 3
tablespoons of whole milk and 2 sugars. 2 cans of Coke. 2
glasses of water

University of South Florida College of Nursing Revision August 2013

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill? John, my fianc, he is such a good guy
How do you generally cope with stress? or What do you do when you are upset?
Sometimes I just keep it in. When its too much Ill let it out and rip someone a new a**hole. But I can take it too.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Thats on and off. I will fall into depression where I dont want to get out of bed, but I try hard to get out of that place.
John helps, he is really positive.

+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? ____Yes, my first marriage
Have you ever been talked down to?_Yes _ Have you ever been hit punched or slapped? _Yes, Ive had black eyes
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_Yes__ If yes, have you sought help for this? __Yes, I was on medication_
Are you currently in a safe relationship? Yes!

4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Intimacy vs. Isolation

Autonomy vs. Doubt & Shame

Initiative vs. Guilt
Industry
Generativity vs. Self absorption/Stagnation XEgo Integrity vs.

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons
developmental stage for your
patients age group:
This patient is currently in Eriksons stage of ego integrity versus despair. Ego integrity involves the acceptance on ones
life, worth, and eventual death. Ego integrity is achieved when the individual is satisfied with their life and has an
understanding of their place in the life cycle. Despair is achieved by fearing death and being uncomfortable with life and

University of South Florida College of Nursing Revision August 2013

aging (Treas & Wilkinson, 2014).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
The patient is in Eriksons stage of ego integrity. She is satisfied with her life and is proud of her accomplishments. The
patient stated she was proud of how she moved up in her job at the factory, and that she is proud of being a cheerleader
and class president in school. She is able to reflect back on hard times in her life and acknowledge her strength in
overcoming them. She understands she is aging and attributes her illness to this fact, but she is excited to live the
remainder of her life alcohol free and with her new fianc.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of
life:
The patients disease has made her come to terms with the fact that she is aging and that life is limited. It has also caused
her to reflect back on her life and be proud of the changes she has made to her lifestyle.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness? ---- I have no idea. Well maybe old age, it creeped up on me

What does your illness mean to you?--- Im angry and upset. Geez im shocked!

+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? _____Men
Are you aware of ever having a sexually transmitted infection? __Never___
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? ____Yes__When sexually active, what measures do you take to prevent acquiring a
sexually transmitted disease or an unintended pregnancy? _No, ive never used a condom
How long have you been with your current partner?__7 years
Have any medical or surgical conditions changed your ability to have sexual activity? _
Well see now when I get home
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision August 2013

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
_A lot because I was brought up catholic. I wanted to be a nun but my dad wouldnt let me. Im trying to get back to the
church.____

Do your religious beliefs influence your current condition?

_They give me strength because I believe this was all written the day I was born.

+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?
How much?(specify daily amount)
Cigarettes (Palmals or 300s)
1 pack a day
Pack Years: 365 packs a year. Total 17,155
lifetime packs

YesX
No
For how many years? 47 years
(age 21

thru

present

If applicable, when did the

patient quit?

Does anyone in the patients household smoke tobacco? If

so, what, and how much?
-Patients fianc smokes 1 to 1 packs per day

Has the patient ever tried to quit?

Yes for a month after the patient had a brain aneurysm.

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes X
No
What? Beer and vodka
How much? (give specific volume)
For how many years?
(age 15 thru
67
a bottle of Vodka a day or
12-14 beers a day
If applicable, when did the patient quit?
Patient stated she quit drinking 91 days ago.
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No X
If so, what?
N/A
How much?
For how many years? N/A
(age
thru
)
N/A
Is the patient currently using these drugs?
Yes No

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
-Patient denies being exposed to any occupational or environmental hazards or risks.

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution

Gastrointestinal

X Recent weight loss or gain

X Nausea, vomiting X, or diarrhea

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

Integumentary

Changes in appearance of skin

Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen NO

SPF:

Bathing routine: 2X Week

Other:

Diverticulitis
Appendicitis
Abdominal Abscess
X Last colonoscopy?- 2000
Other:

HEENT

X Difficulty seeing L eye blind

Cataracts or Glaucoma
X Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
X Dental problems

Genitourinary

X nocturia
X dysuria---recent
hematuria
polyuria
kidney stones
Normal frequency of urination:
10
x/day
X Bladder or kidney infections

Immunologic

Chills with severe shaking

X Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic
reaction
Enlarged lymph nodes

Other:
Hematologic/Oncologic

Anemia
Bleeds easily
X Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
Metabolic/Endocrine

XRoutine brushing of teeth

Routine dentist visits

x/year

NO

Diabetes

x/day

Type:

Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Vision screening No

Other:
Pulmonary

X Difficulty Breathing
X Cough - dryX or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis

irregular

Environmental allergies
Xlast CXR? 8/29/2015
Other:

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
X menarche
age? 10
X menopause
age? 53
Date of last Mammogram &Result:
1995

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

University of South Florida College of Nursing Revision August 2013

Cardiovascular

X Hypertension
X Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
X CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
X Last EKG screening, when?
09/02/2015
Other:

Date of DEXA Bone Density &

MEN ONLY
Infection of male
genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

Mental Illness

X Depression
Schizophrenia
X Anxiety
Bipolar
Other:

Musculoskeletal

Injuries or Fractures
X Weakness
X Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases

Measles
Mumps
Polio
Scarlet Fever
X Chicken Pox
Other:

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
I was previously hospitalized for suicide attempts.
Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision August 2013

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey: Patient is a
68 year old obese female who
appears well groomed. Pt.
appears free from distress and
is alert and oriented X3.
Temperature: (route taken?)
98.3- Temporal

Height: 56
Pulse: 69

Weight: 255 lbs BMI: 41.2

Blood
Pressure:

Pain: (include rating & location)

5 out of 10. Abdomen

(include location)

137/68Left arm
Respirations: 18
SPO2: 94% on Room Air

Is the patient on Room Air or O2: Room air

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
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
Other:
Integumentary
X Skin is warm, dry, and intactwith exception to right
groin dressing which is dry.
X Skin turgor elastic---with slight tenting
X No rashes, lesions, or deformities
X Nails without clubbing
X Capillary refill < 3 seconds
X Hair evenly distributed, clean, without vermin

X Peripheral IV site Type: 20G

X no redness, edema, or discharge
Fluids infusing? X no
yes - what?
Peripheral IV site Type:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Fluids infusing?
no
yes - what?

Location: Right forearm

Location:

Location:

flat
loud

Date inserted: 9/1/2015

Date inserted:

Date inserted:

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 3/ mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
X Ears symmetric without lesions or discharge X Whisper test heard: right ear- 2
inches & left ear5 inches
X Nose without lesions or discharge X Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
Comments: Peripheral vision intact and EOM through 6 fields without nystagmus on right eye. No peripheral vsion on left
eye due to left unilateral blindness.

University of South Florida College of Nursing Revision August 2013

Pulmonary/Thorax:X Respirations regular and unlabored XTransverse to AP ratio 2:1 XChest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
XPercussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished

Upper lobes bilaterally clear to auscultation. Right middle lobe clear. Left
bilateral lower lobes diminished.

S Stridor
Ab - Absent

Cardiovascular: XNo lifts, heaves, or thrills PMI felt at: 5th intercostal space, midclavicular line
Heart sounds: S1 S2 X Regular
Irregular
XNo murmurs, clicks, or adventitious heart sounds
XNo JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze) : Normal sinus rhythm with intermittent
ST elevation.

University of South Florida College of Nursing Revision August 2013

NSR

University of South Florida College of Nursing Revision August 2013

X Calf pain bilaterally negative X Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3
Carotid: 2
Brachial: 3
Radial: 3
Femoral: 2
Popliteal: 2
DP: 2
PT:2
X No temporal or carotid bruits
Edema: 1 trace non pitting edema
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm),
(5-6mm),

+3

+4(7-8mm) ]

Location of edema: Bilateral lower extremities

X Extremities warm with capillary refill less than 3 seconds

pitting

non-pitting

GI/GU: 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
Abdomen non-tender to palpation
Urine output: X Clear
Cloudy
Color: Yellow
Previous 24 hour output:
1200
mLs
N/A
Foley Catheter
Urinal or Bedpan X Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 9 / 3 / 2015 )
Formed X Semi-formed
Unformed
X Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red

Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

X Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

X Strength bilaterally equal at __4_____ 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 parathesias

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
X 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: 2

Patellar2:

Achilles: 2

Ankle clonus: positive negative Babinski: positive

negative

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.
WBC: normal- 4.5-11
Hct: normal- 33-43
Total Protein: normal- 6.4-8.3
9/1/15: 7.2
9/1/15: 40.1
9/2/15: 5.3(low)
9/3/15: 10.4(trending up)
9/3/15: 40.4
Hgb: normal- 12-16g/dL Neutro Auto: normal- 45-75 Lymph Auto: normal 20-50
University of South Florida College of Nursing Revision August 2013

9/1/15: 13.1
9/1/15: 65.7
9/1/15: 20.9
9/3/15: 13.2
9/3/15: 83.0(high/trending up) 9/3/15: 10.6(low/trending down)
BUN: normal 7-18
Creatinine: normal 0.6-1.2
Sodium: normal 135-145
9/1/15:10
9/1/15: 0.8
9/1/15: 138
9/3/15: 9
9/3/15: 0.7
9/3/15: 136
Potassium: normal 3.5-4.5 Albumin: normal 3.5-4.8
9/1/15: 4.4
9/2/15: 3.0(low)
9/3/15: 4.5
Amylase: normal- 28-100 Triglyceride: goal<150 PH: normal 7.35-7.45 HCO3 calc: normal 22-26
9/3/15: 27(low)
9/1/15: 178
9/1/15: 7.39
9/1/15: 26.8(high)
LDL: goal <100
Cholesterol goal< 200 pCO2: normal 35-45
9/1/15: 102
9/1/15: 174
9/1/15: 44.5
HDL: goal >50(female)
Lipase: normal- 22-51 pO2: normal 80-100
9/1/15: 36(low)
9/3/15: 14(low)
9/1/15: 77.3(low)
Analysis
The patients white blood cells and neutrophil counts are trending up, while her lymphocytes are trending down,
this could be due to the inflammatory process post cardiac catheterization or could indicate the start of a new
infection. The patients low total protein and low albumin levels may be caused by a decreased nutritional state or
from liver dysfunction due to the patients history of alcohol abuse. Her low amylase and lipase levels may also
be due to liver damage from alcohol abuse or could indicate pancreatic insufficiency. Her BUN and creatinine
levels are within normal ranges indicating no acute sign of kidney dysfunction. HDL levels below 40 are
associated with an increased risk for heart disease, the patients HDL level of 36 and high triglyceride level of 178
are contributors to her coronary artery disease. The patients high normal pCO2, normal pH, and increased HCO3
shows COPD compensation. The pH remains within the normal range for patients with COPD due to renal
compensation and increased levels of HCO3 as pCO2 levels rise. (Osborn et al., 2010)
Diagnostic tests:
-8/21/15: CT scan- Revealed 5.1cm abdominal aortic aneurysm without dissection
-8/21/15: Chest X-ray- Mild aortic calcifications. No free air in the abdomen. No pneumothorax. Suspect COPD
-9/2/15: Cardiac Catheterization- Multi vessel coronary artery stenting involving two stents to the right coronary
artery, three stents to the left anterior descending artery, and one stent to the circumflex vessel. Normal left
ventricle systolic function.
-9/3/15: KUB- No evidence of bowel distention or obstruction.
-9/4/15: Bilateral Carotid Duplex Scan: 70% stenosis of the left carotid artery, 50-69% stenosis of the right
internal carotid artery.
-9/4/15: CT angiogram of the neck- atherosclerosis of aortic arch. Prominent ulcerated soft plaque within distal
right common carotid.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled
diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
Treatment plan for the patient currently includes: vitals every eight hours, cardiac diet, activity as tolerated,
SCDs, PO ordered medications, and discharge dependent on clearance from cardiologist. At this time the patient
is not a good candidate for aortic aneurysm repair or correction of carotid stenosis due to her obesity, COPD, and
cardiac condition. The abdominal aortic aneurysm will be followed as an outpatient with ultrasounds every six
months to monitor aneurysm growth. Surgical repair will be indicated when the aneurysm reaches 5.5cm.
8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Risk for shock related to inadequate blood flow to tissues if aneurysm ruptures.

University of South Florida College of Nursing Revision August 2013

2. Acute pain related to aneurysm pressing against nerves as evidenced by patient rating pain 9 out of 10 on the 0 to
10 pain scale, seeking emergency treatment for pain level, inability to deep breath, and decreased appetite.
3. Ineffective health maintenance related to insufficient resources and ineffective individual coping as evidenced by
demonstrated lack of knowledge of basic health practices, history of lack of health-seeking behavior, and lack of
expressed interest in improving health behaviors.

University of South Florida College of Nursing Revision August 2013

 15 CARE PLAN
Nursing Diagnosis: Risk for shock related to inadequate blood flow to tissues if aneurysm ruptures
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care
Goal
Provide References
is Provided
-Patients vital signs will remain
-Blood pressure, MAP, heart rate,
-The beginning phases of shock are -Patients vital signs remained
stable.
heart sounds, respiration,
associated with decreased tissue
within the normal expected range
temperature, and oxygen saturation perfusion. Hypotension, heart rate
for the patient.
will be monitored every 4 hours.
>90BPM, respirations >20/min,
temperature above 38 degrees
Celsius or below 36 degrees
Celsius, and SpO2 <90% are
indicators of shock (Ackley &
Ladwig, 2014)
-Patients skin will remain warm
-Patients skin color and
-Cool, clammy, mottled, and
-Patients skin remained dry, warm,
and of normal color for ethnicity
temperature will be assessed every cyanotic skin can indicate
and of appropriate color for
4 hours.
inadequate tissue perfusion
ethnicity.
(Ackley & Ladwig, 2014).
-Patients peripheral pulses will
-Peripheral pulses will be assessed -If aneurysm ruptures and shock
-Peripheral pulses were palpable.
remain palpable
every 4 hours.
occurs blood flow to the periphery Dorsal pedis pulses were weak, but
will be dramatically
consistent with previous
reduced/stopped. Assessing
assessments.
peripheral pulses therefore assesses
for signs of adequate or reduced
blood flow.
-Patient will continue to have urine -The patient will be given a hat to
-A urine output of less than 30
-Patient voided 2100 mL for the
output of 30ml/hr or more.
urinate into. Output will be
mL/hr can indicate hypovolemia or previous 24hr.
recorded after each urination, and
decreased renal perfusion (Ackley
total output will be assessed every
& Ladwig, 2014).
4 hours.
-By discharge patient will verbalize -*Educate patient to seek
-Early recognition of signs of
-Patient described signs in which
and recognize signs and symptoms immediate treatment for new onset rupture can lead to earlier treatment she would seek immediate health
of when to seek immediate medical of extreme pain that radiates to the and better outcomes.
care attention including: extreme
attention.
back, hypotension, change in
pain that radiates to the back,
mental status, cool clammy skin,
blurred vision, change in mental
fatigue, dizziness, tachycardia,
status, cool clammy skin, and
increased respiratory rate, and
increased heart rate. Patient

blurred vision.
-Patient will maintain usual level of -Level of consciousness will be
consciousness
assessed every 4 hours by asking
the patient if she knows where she
is, what day of the week it is, and
who the president is.
-Patient will verbalize activity
-*Educate patient to not preform
restrictions by end of shift.
any heavy lifting, play any contact
sports, or perform any action that
may cause her to bear down.

-Decreased level of consciousness

can indicated decreased cerebral
perfusion-a potential sign of
aneurysm rupture and shock.

-Monitor electrocardiogram every

4 hours.

-If tissues are not being perfused

and oxygen demand rises cardiac
dysrhythmias may occur.
-Knowledge empowers patients to
take more active roles in their
medical care (Ackley & Ladwig,
2014).

-Patient will understand the disease

process of an abdominal aortic
aneurysm and will verbalize plan
of care by end of shift.

-Place patient of telemetry as

ordered. Assess ecg every 4 hours
and when alarm limits are violated.
- Educate patient on disease
process of abdominal aortic
aneurysm and rationale for plan of
care.

-Heavy lifting, contact sports, and

bearing down increase the risk of
aneurysm rupture.

described how she would take her

pulse.
-Patient maintained her usual level
of consciousness, alert and oriented
X 3.
-Patient verbalized that she will not
do any heavy lifting, participate in
any contact sports, and will take
stool softeners to reduce strain
while having a bowel movement.
-Patient remained in normal sinus
rhythm for entire shift.
-Patient verbalized an
understanding of the disease
process of an abdominal aortic
aneurysm and verbalized
understanding for plan of care
including outpatient follow up
appointments.

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
XDietary Consult
PT/ OT
XPastoral Care
Durable Medical Needs
XF/U appts
XMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? XYes No
Rehab/HH

 15 CARE PLAN
Nursing Diagnosis: Acute pain related to aneurysm pressing against nerves as evidenced by patient rating pain 9 out of 10 on the 0 to 10 pain scale, seeking
emergency treatment for pain level, inability to deep breath, and decreased appetite.

Patient Goals/Outcomes
-Patient will use the 0 to 10 pain
scale to self report pain and
identify an acceptable pain goal by
end of shift.

-Patient will describe nonpharmacological methods that can

be utilized to help achieve pain
goal by end of shift.
-Patient will state the ability to
obtain sufficient amount of sleep
by discharge.

Nursing Interventions to Achieve

Goal
- Describe how to rate pain using
the 0 to 10 pain scale to the patient.
Ask the patient to identify an
acceptable pain level for them.

Rationale for Interventions

Provide References
-Single dimension pain ratings are
valid and reliable as measurements
of pain intensity level (Ackley &
Ladwig, 2014). Having the patient
choose their acceptable pain level
increases patient satisfaction and
effective pain management.
-Non pharmacological pain
reduction can effectively aid in the
reduction of pain.

-*Educate patient on nonpharmacological methods of pain

management such as heat, position
change, and breathing exercises.
-Administer pain medication before -Sleep is a vital for healing.
bedtime. Reduce noise audible in
Minimizing pain before bed can
patients room.
increase the number of hours a
patient is able to sleep.
-Patient will notify health care
-For elevated pain levle adjunctive -Unrelieved pain can have negative
team for pain level that is
prn medications will be
physiological and psychological
consistently higher than pain goal. administered. For consistently
consequences that contribute to
unrelieved pain the provider will be negative patient outcomes (Ackley
notified with a recommendation for & Ladwig, 2014).
increased dosage or medication
alternative. Educate patient on the
adverse effects of unrelieved pain.
-Patient will obtain a pain level less -Pain level will be assessed every 4 -Patients pain level should be
than or equal to pain goal by end of hours and one hour after
assessed at times of rest and
shift.
administration of pain medication. movement (Ackley & Ladwig,
Pain medications will be
2014). Administration of pain
administered as ordered.
medications as ordered will help
reduce pain and evaluation will
determine if the current pain
management plan is effective.
-Patient will report onset of any
-*Educate patient on potential side -Opioids can cause constipation
pain medication side-effects as
effects for the specific medications and decreased respirations.

Evaluation of Interventions on
Day care is Provided
-Patient utilized the 0 to 10 pain
scale and identified a pain level of
4 as acceptable.

-Patient verbalized positions in

which decreased her pain level.
-Patient stated she was unable to
sleep well the previous night and
medication alternatives were
discussed.
-Patient obtained a pain level of 5
which is higher than her pain goal,
but stated she did not feel her pain
was consistently higher than her
goal.

-Patient reported her pain level as a

5 at end of shift. Patient did no
reach pain management goal.

-Patient reported constipation, stool

softeners and laxatives were

soon as they appear.

administered such as- nausea,

pruritis, and bowel eliminations;
and educate patient on importance
of timely reporting of symptoms.
Assess patients respiratory status
when administering opioid
analgesics.

Prevention and early detection of

side effects increases positive
patient outcomes.

administered.

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
XDietary Consult
PT/ OT
XPastoral Care
Durable Medical Needs
XF/U appts
XMed Instruction/Prescription
are any of the patients medications available at a discount pharmacy? XYes No
Rehab/ HH
Palliative Care

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th
ed.). Maryland Heights, Mo.: Elsevier.
Huether, S., & McCance, K. (2012). Alterations of Cardiovascular Function. In Understanding pathophysiology
(5th ed.). St. Louis, Mo: Elsevier.
Osborn, K., Wraa, C., Watson, A., & Holleran, R. (2010). Medical-surgical nursing: Preparation for practice
(2nd ed.). Upper Saddle River, N.J.: Pearson Prentice Hall.
SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved October 3, 2015, from
https://www.supertracker.usda.gov/foodtracker.aspx
Treas, L., & Wilkinson, J. (2014). Development: Infancy Through Middle Age. In Basic nursing: Concepts,
skills, & reasoning. Philadelphia, PA: F.A. Davis Company.