UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Taylor Kelly

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 10/16/15

Agency: VA-SBN

Patient Initials: R.W.M.

Age: 67

Admission Date: 09/24/15

Gender: M

Marital Status: Married

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Atrial fibrillation (I48.1)

Level of Education: Some college

Other Medical Diagnoses: (new on this admission)

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

No new diagnoses

Number/ages children/siblings: 1 son, 30 yoa

Served/Veteran: Yes

Code Status: Full Code

Living Arrangements: Lives at home with wife

Advanced Directives: No
If no, do they want to fill them out? Yes
Surgery Date: 09/28/15
Procedure: Cardiac ablation

Culture/ Ethnicity /Nationality: Caucasian

Religion: Catholic

Type of Insurance: Medicare, Medicaid

1 CHIEF COMPLAINT:
Abnormal heart rhythm. The patient came into the clinic on 09/10/15, where they scheduled cardiac ablation for 09/28/15.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
The patient was admitted on 09/24/15 for a scheduled cardiac ablation due to a history of atrial fibrillation with activity
intolerance. After the cardiac ablation was preform, the patient has remained in sinus rhythm. The patient also has a
history of type II diabetes mellitus, hypertension, and gout. The patient reports dyspnea at night and uses 2L of oxygen at
night time only. The patient reports no pain, and vitals remain stable.

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

89

Mother

87

Sister

65

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Asthma

Cause
of
Death
(if
applicable
)
COPD
Pneumoni
a
N/A

Arthritis

2
FAMILY
MEDICAL
HISTORY

Age (in years)

09/28/15

Anemia

2013

Environmental
Allergies

Diabetes Type II
Hypertension
A-fib
Gout
Cardiac Ablation

Alcoholism

2009

Comments: Include date of onset- Patient was unsure

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 10/2014
Adult Tetanus 10/2014
Influenza (flu) 10/2014
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent
ZOCOR

Type of Reaction (describe explicitly)

Muscle pain

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)
Atrial fibrillation is a cardiac arrhythmia that occurs when the atria fails to contract and release completely, resulting in
blood pooled in the atria unejected to the ventricles. The cardiac arrhythmia occurs when the electrical impulse from the
SA node fails to being the heart beat in a regular 60 to 100 beats per minute. Instead, the faulty SA node doesnt allow the
AV node to fire in a regular beat, causing the irregularly. Because the SA node is sending impulses sporadically and
quickly, the atria begin to quiver, instead of completely contracting blood into the ventricles, and relaxing fully to fill up
with blood (Ferrari et al., 2015).
Atrial fibrillation puts a patient at greater risk for clotting and stroke. Atrial fibrillation can be treated pharmaceutically
with anticoagulants and antiarrhythmic; it can also be treated with surgically with electric cardioversion and cardiac
ablation (Ferrari et al., 2015).

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

Concentration (mg/ml)

Route PO

Dosage Amount 300 mg

Frequency QDaily

Pharmaceutical class xanthine oxidase inhibitor

Home

Hospital

or

Both

Indication Prevention of gout arthritis and neuropathy

Side effects/Nursing considerations: Hypotension, hypertension, bradycardia, rash, drowsiness. Instruct patient to take as prescribed, and to report skin rash.
Name apixaban (Eliquis)

Concentration

Dosage Amount 5 mg

Route PO

Frequency BID

Pharmaceutical class Factor xa inhibitors

Home

Hospital

or

Both

Indication Decrease risk of stroke associated with A-fib

Side effects/Nursing consideration: Bleeding. Instruct patient to report any excess bleeding/bruising. Check INR regularly.
Name flecainide (Tambocor)
Route

Concentration

Dosage Amount 100 mg

PO

Frequency Q12H

Pharmaceutical class Antiarrhythmic

Home

Hospital

or

Both

Indication A-fib
Side effects/Nursing considerations: Dizziness, H/A, blurred vision, arrhythmias, chest pain, rash, tremor. Do not take with calcium channel blockers, monitor
EKG periodically, monitor I&Os.

University of South Florida College of Nursing Revision August 2013

Name furosemide (Lasix)

Concentration

Dosage Amount 40 mg

Route PO

Frequency Q AM

Pharmaceutical class Loop diuretic

Home

Hospital

or

Both

Indication Edema, HTN

Side effects/Nursing considerations: Dizziness, H/A, hypotension, hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia. Check potassium levels
regularly, monitor I&Os, daily weights, edema, lung sounds.
Name hydrochlorothiazide (Microzide)
Route

Concentration

Dosage Amount 25 mg

PO

Frequency QDaily

Pharmaceutical class Thiazide diuretics

Home

Hospital

or

Both

Indication Management of mild to moderate hypertension

Side effects/Nursing considerations: Dizziness, H/A, hypotension, hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia. Check potassium levels
regularly, monitor I&Os, daily weights, edema, lung sounds.
Name insulin glargine (Lantus)
Route

Concentration 60 units

SubQ

Dosage Amount

Frequency

Pharmaceutical class Pancreatics

Home

Hospital

Q AM
or

Both

Indication Control of hyperglycemia in Diabetes Mellitus Type II

Side effects/Nursing considerations: Hypoglycemia. Check blood glucose levels every 6 hours, assess for symptoms of hypoglycemia.
Name potassium chloride (KCl)

Concentration

Dosage Amount 20mEq

Route PO

Frequency Q AM

Pharmaceutical class Mineral and electrolyte replacements

Home

Hospital

or

Both

Indication Prevention/ treatment of hypokalemia

Side effects/Nursing considerations: Arrhythmias, EKG changes, GI ulceration. Assess for signs and symptoms of hypokalemia

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? 2000 CHO Diabetic
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: Oatmeal and juice
Lunch: Sandwich, chips
Dinner: Meatloaf, mashed potatoes, broccoli
Snacks: Chips, or crackers
Liquids (include alcohol): Juice with breakfast, sometimes
milk, water
According to My Plate, the patient eats 1,784 calories per
day of his allotted 2,000. However, the patient eats elevated
levels of oils, sodium, and refined grains compared to the
recommend diet. Also, the patient only consumed about
25% of the recommend whole grains, only 75% of
recommended protein, and 50% of fruits recommended.
My Plate recommends eating three cups of dairy daily,
whereas the patient only ate of a cup (5%) of the
recommendation.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
- Wife
How do you generally cope with stress? or What do you do when you are upset?
- I enjoy reading, watching TV, spending time with family

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
- Being in the hospital (feeling overwhelmed)

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? No

Have you ever been hit punched or slapped? No

Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No
If yes, have you sought help for this? N/A
Are you currently in a safe relationship? Yes

University of South Florida College of Nursing Revision August 2013

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
- The patient reflects back on their life and either feels that it was meaningful (integrity) or does not feel satisfied

with their life accomplishments (despair) (Hearn et al., 2012).

Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
- The patient exhibits signs of integrity; his overall affect is positive and confident. He is a proud husband, father,

and grandfather.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:

It seems that the patients developmental stage of life has been unaffected by his illness. His illness is not as
debilitating, therefore he is still able to enjoy his family and his hobbies.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
- Getting older
What does your illness mean to you?
- Patient states that it limits him at times, but generally doesnt impact him too much.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? 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? None
How long have you been with your current partner? 31 years
Have any medical or surgical conditions changed your ability to have sexual activity? No
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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?
- The patient states that his religion is highly important to him

Do your religious beliefs influence your current condition?

The patient believes that his beliefs keep him positive about life.

+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)

Yes
No
For how many years? X years
(age

thru

If applicable, when did the

patient quit?

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

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)

For how many years?

(age

thru

If applicable, when did the patient quit?

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

Is the patient currently using these drugs?

Yes No

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
- None

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
2014
Other:

Chills with severe shaking

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

Genitourinary

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

nocturia
dysuria
bladder scan was preformed
hematuria
polyuria
kidney stones
Normal frequency of urination:
6/day
Bladder or kidney infections

Hematologic/Oncologic

Metabolic/Endocrine
2/day
2/year

Diabetes
Type: II
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?
Other:

Central Nervous System

PND

2012

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Daily
Other:
(On Telemetry unit)

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
1/year
Date of last prostate exam?
2014
BPH
Urinary Retention

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

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

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 August 2013

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

General Survey: 67 year old Height: 55
male with no signs of distress Pulse: 88
Temperature: (route taken?)
Respirations: 18

Weight: 242 BMI: 39.16

Blood
Pressure: 107/65 (brachial)

Pain: 0

(include location)

SpO2 : 98%
Is the patient on Room Air or O2: 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
- Slightly lethargic due to hyperglycemia
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
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

Peripheral IV site Type: Hep. Lock

no redness, edema, or discharge
Fluids infusing?
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?

talkative
withdrawn

Location: Right forearm

Location:
Location:

quiet
boisterous
aggressive
hostile

flat
loud

Date inserted: 09/27/15

Date inserted:
Date inserted:

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 2/ 2 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- ~20 inches & left ear- ~20 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Normal
Comments:

University of South Florida College of Nursing Revision August 2013

10

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion 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
S Stridor
Ab - Absent

Clear- LUL, RUL

Diminished- LLL, RML, RLL

Cardiovascular:
No lifts, heaves, or thrills PMI felt at:
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Patients EKG has been sinus rhythm since cardiac ablation on 09/28/15.

Calf pain bilaterally negative

Pulses bilaterally equal: 3- normal
Apical pulse: 88
Carotid:
Brachial: 88
Radial: 88
Femoral:
No temporal or carotid bruits
Edema: 0- none
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

Popliteal:

DP:

PT:

GI/GU:
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
Urine output:
Clear
Cloudy
Color: Clear yellow
Previous 24 hour output: 700 mLs (low)
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness
Last BM: (date 09/28/15)
Formed
Semi-formed
Unformed
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:

Not assessed, patient alert, oriented, denies problems

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 parathesias

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: +1

Biceps: +2

Brachioradial: +2

Patellar: +2

Achilles: +1

Ankle clonus: positive negative Babinski: positive negative

Slight diabetic neuropathy in lower extremities

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Active Clotting Time
168 H
349 H
309 H

Dates
(09/28/15) @
1241
1143
1028

Normal (80-160 secs.)

Whole Blood Glucose

341 H
216 H
216 H
193 H
191 H
Normal (70-100)

(09/29/15) @
1042
0540
(09/28/15) @ 2159
1608
1328

Trend
The patients active
clotting time is
continuously high.
The patient is on an
anticoagulant for A-fib.

Analysis
The average time it takes
the blood to clot (in
seconds). Usually an
elevated active clotting
time is negative, however
it may be a positive
indication in this patient
d/t his A-fib.

The patients whole blood

glucose is continuously
high. The patient receives
accuchecks 4 times per
day.

The amount of glucose in the

blood. The consistent
elevation in whole blood
glucose indicates that the
patients type II diabetes is
not well-controlled. Diabetic
patients with high blood
glucose may need to consider
a change in treatment.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
-

Diet: 2000 Cal CHO

Accuchecks: Four times daily
Constant EKG (telemetry floor)

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

1.

Unstable blood glucose related to medication management, as evidence by chronic hyperglycemia, and feeling
symptoms of high blood sugar regularly.

2.

Activity intolerance related to imbalance between oxygen supply and demand, as evidence by the need for external
oxygen use at night (paroxysmal nocturnal dyspnea), diminished lung sounds, and history of atrial fibrillation.

3. Risk for disturbed sensory perception related to glucose/insulin imbalance.

 15 CARE PLAN
Nursing Diagnosis: Unstable blood glucose related to medication management, as evidence by chronic hyperglycemia, and feeling symptoms of high
blood sugar regularly.

Patient Goals/Outcomes
Short Term:
1. Bring patients blood glucose levels
back down into the normal range,
within a few hours.

2. Tightly manage the patients blood

glucose levels every shift.

Long Term:
1. Increase patients ability to manage
his blood glucose levels at home.

Nursing Interventions to Achieve

Goal

Rationale for Interventions

Provide References

Evaluation of Goal on Day care is

Provided

1. Perform accucheck, notify the

provider of chronic hyperglycemia,
administer insulin as ordered, reassess
patient for signs and symptoms of
hypo/hyperglycemia.

1. The patient has been assessed and

exhibits signs and symptoms of
hyperglycemia. The priority is to
lower his blood glucose levels to
prevent further damage.

1. The goal was not met, by the end of

shift the patients blood glucose levels
were still elevated.

2. Perform accuchecks every 4 hours,

assess patient regularly for signs and
symptoms of hypo/hyperglycemia.

2. If the patient is able to keep his

blood glucose levels within the normal
limits, he will be at a lower risk of
neuropathy, organ damage, and
infection.

2. The goal was not met, by the end of

shift the patients blood glucose levels
were still elevated.

1. Provide patient education about the

importance of CHO diabetic diet, at
home accuchecks, and knowing the
signs and symptoms of
hyper/hypoglycemia.

1. If the patient is able to keep his

blood glucose levels within the normal
limits, he will be at a lower risk of
neuropathy, organ damage, and
infection.

1. Patient was provided with education

about his medications, and the types of
insulin, and the signs of
hyperglycemia.

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 appts
*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Through VA
Rehab/ HH
Palliative Care

 15 CARE PLAN
Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand, as evidence by the need for external oxygen use at
night (paroxysmal nocturnal dyspnea), diminished lung sounds, and history of atrial fibrillation.

Patient Goals/Outcomes

Nursing Interventions to Achieve

Goal

Rationale for Interventions

Provide References

Short Term:
1. Keep the patients oxygen levels
stabilized every shift.

1. Assess patient at least every 4 hours

(SpO2, LOC, HR, RR, BP).

1. The patient currently has an oxygen

imbalance at night while sleeping,
therefore it is important to make sure
he is not experiencing dyspnea at any
other time.

1. The goal was met. The patients

vitals remained stable through out the
entire shift, with no reports of
dyspnea.

2. Work with the patient every shift to

increase the patients ability to tolerate
activity, and alleviate symptoms of
PND .

2. Assess patient at least every 4

hours. Encourage the patient to slowly
increase activity level (go for a short
walk), and use of incentive spirometer.

2. If the patient is able to increase his

activity level, he will at a lower risk of
dyspnea (day and night), and will be
more comfortable, and stay
independent much longer.

2. The goal was not met because the

patient was not able to perform any
activity/walking due to his
hyperglycemia.

3. Increase patient compliance with

medication used to optimize oxygen
use, as ordered by the provider.

2. Administer the appropriate

medications in order for the patient to
optimize oxygen use, as ordered by
the provider.

3. If the patient is taking all of his

prescribed medications, the level of
oxygen supply/demand should remain
stable.

3. The goal was met. The patient

received all prescribed medications on
time including: apixaban, flecainide,
and hydrochlorothiazide.

1. Assess the patients ability to

complete ADLs, and encourage the
patient to increase activity level by
walking short distances every day.
Provide patient education on PND,
and how to ease the symptoms.

1. If the patient is able to increase his

activity level, he will at a lower risk of
dyspnea (day and night), and will be
more comfortable, and stay
independent much longer.

1. The goal was partially met; the

patients vitals remained stable
through out the entire shift, with no
reports of dyspnea. However, the
patient was not able to perform any
activity due to his hyperglycemia.

Long Term:
1. Slowly increase the patients ability
to tolerate activity, and decrease the
need for external oxygen use at night
before discharge.

Evaluation of Goal on Day care is

Provided

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 appts

*Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Through VA
Rehab/ HH
Palliative Care

References
Ferrari, R., Bertini, A., Blomstrom-Lundqvist, C., Dobrev, D., Kirchhof, P., Pappone, C., & ... Vicedomini, G.
(2015). An update on atrial fibrillation in 2014: From pathophysiology to treatment. International
Journal Of Cardiology, doi:10.1016/j.ijcard.2015.10.089
Food Tracker. (n.d.). Retrieved July 14, 2015, from https://www.supertracker.usda.gov/foodtracker.aspx

Hearn, S., Saulnier, G., Strayer, J., Glenham, M., Koopman, R., & Marcia, J. (2012). Between Integrity and
Despair: Toward Construct Validation of Erikson's Eighth Stage. Journal Of Adult Development, 19(1),
1-20. doi:10.1007/s10804-011-9126-y
Unbound Medicine, Inc. and Vallerand, Sanoski, Deglin & Mansell. (2015). Daviss Drug Guide
(1.26.) [Mobile application software]. Retrieved from
<http://www.unboundmedicine.com/products/nursing_central>