Patient Assessment Student Work Sheet PDF

# NURS 3232 Adult Health Competencies I ## Texas Woman's University ### Patient Assessment Student Work Sheet **Student's Name:** Clarisse Okonma **Pt. Initials:** W.A **Age:** 58 **Gender:** M **Date of Care:** 10/31/2024 **Language Preference:** English **Code Status:** Full Code **Ethnicity:...

# NURS 3232 Adult Health Competencies I ## Texas Woman's University ### Patient Assessment Student Work Sheet **Student's Name:** Clarisse Okonma **Pt. Initials:** W.A **Age:** 58 **Gender:** M **Date of Care:** 10/31/2024 **Language Preference:** English **Code Status:** Full Code **Ethnicity:** African American **Spiritual Preference:** Christian **Allergies:** Excedrin **Isolation:** * **None:** X * **Contact:** _ * **Droplet:** _ * **Airborne:** _ **Isolated for (what micro-organism):** N/A **Admission Date and Medical Diagnosis:** (When admitted and why admitted) Admitted on 10/29/2024 for acute diastolic heart failure, elevated troponin levels, and respiratory distress **Course of current illness (What happened at home/ nursing home that led to their admission and what has happened since being admitted. What is their story?)** The patient presented to the ED after experiencing worsening shortness of breath and peripheral edema over the past weeks. At home he struggled with managing his alcohol consumption, leading to increased anxiety and physical distress. Upon admission, he exhibited elevated troponin levels. His wife expressed concern about his alcohol problem and its potential for him to go through withdrawal. **Co-Morbidities or chronic problems with dates (e.g. Diabetes 1998, HTN 2001, COPD 2015)** * **Hypertension:** 2015 * **Hyperlipidemia:** 2015 * **Alcohol Use Disorder:** 2021 **Past medical and surgical history with dates** * **Angioplasty:** 2019 **Psycho-social Information (Married? Working? Lives alone?-helps to plan for discharge)** The patient is married with children and grandchildren. His wife is actively involved in his care and is concerned about his health and alcohol use. He lives with his family and has support from them during his hospital stay. ## Scheduled Medications: **Tip:** Look at adverse side effects/warnings to guide priorities for assessment and monitoring. | Medication Generic/Brand or Trade name | Dosage and Route | General Drug class | Why Patient is getting | Nursing Assessment and Monitoring | Patient Teaching | |---|---|---|---|---|---| | Atorvastatin | 40 mg orally | Statin | To manage and reduce LDL | Monitor lipid levels, liver function tests and rhabdomyolysis | Advise about dietary changes adherence to meds | | Carvedilol | 12.5 mg orally | Beta- Blocker| Manage HTN | Monitor Hr and BP. watch for signs bradycardia | Instruct on how to take medications and do stop taking abruptly | | Furosemide | 40 mg IV | Loop Diuretic | To reduce fluid overload due to HF | Monitor I&O's, daily weight, electrolyte levels. and signs of dehydration | Educate on the importance of not taking this drug at night | ## PRN Medications | Medication Generic/Brand or Trade name | Dosage and Route | General Drug class | Why Patient is getting | Nursing Assessment and Monitoring (must have for medications you are giving) | Patient Teaching (must have for medications you are giving) | |---|---|---|---|---|---| | Morphine | 2-4 mg IV | Opioid Analgesics | For management of acute pain or anxiety due to withdrawal | Assess pain level (scale -10) respiratory status, sedation level | Instructs patient on pain management and when to request medeication | ## Tests | Tests | Date drawn | Results | Normal or abnormal? Why Important for your patient? Pathophysiology | |---|---|---|---| | WBC &Neutrophils | 10/29 | 7000/uL | Normal, indicates patients body is fighting an infection | | PLT | | 335 | Normal, Patients ability to form clots and access bleeding risks | | PT/INR *PT | | PT: 12 sec; INR 1.0 | Normal, assess bleeding risks | | PTT | | 35 sec | Normal, assess the coagulation pathways, and monitor heparin | | HgB | | 13.5 g/dL | Normal, measure o2 carrying capacity | | Hct | | 40% | Normal, Measures the blood volume of the RBC | | Na | | 13.5 mEq/L | normal, regulates fluid balance critical for muscle nerve function | | K | | 2.0 mEq?L | Abnormal, important for cardiac and muscle tissue | | CI | | 100 mEq/L | Normal, maintains fluid balance | | Osmolality | | 285 mOsm/kg | Normal, assess concentration of solutes in blood | | BUN | | 30 mg/dL | Abnormal,, key indicator of renal function an fluid overload | | Creatinine | | 1.8 mg | abnormal, shows the functionality of the kidneys | | Glucose | | 90 mg/dL | Normal, measures blod sugar | | Albumin | | 4.0 g/dL | Normal. measures nutritional status and liver function | | Ca (Serum or Ionized?) | | 9.0 mg/dL | Normal, important for bone health, muscle function, and nerves | | Mg | | 2.0 mg/dL | Normal, plays a role in muscle and nerve function | | CK | | 150 u/L | Normal. indicates hearts musice damage | | CK-MB | | 5 ng/mL | Normal, cardiac marker for cardiac damage and MI | | Troponin | | 0.05 ng/mL | Abnormal and helps diagnose heart attacks | | Arterial: pH | | 7.40 | Normal. pH indicates acidosis/alkalosis | | PaCO2 | | 40 | Normal, co2 refects respiratory function | | PaO2 | | 95 mmhg | Normal, affects o2 levels and oxygenation | | HCO3 | | 24 mEq/L | Normal, metabolic balance for acid base balance | | BE | | 0 | Normal, Base excess tells metabolic balance. | | Urinary: pH | | 6.0 | Normal. affects crystal formation | | Specific gravity | | 1.020 | Normal Assess kidney concentration ability and hydration status | | sodium | | 140 mEq/L | Normal, important for assessing fluid blance and kidney function | | osmolality | | 300 mOsm/kg | Normal, reflects hydration status | | GFR | | 90 mL/min | Normal, indicates kidney function, lower values show kidney impairment | | Culture Reports | | Negative | Normal, indicates presence of infection, guides antibiotic therapy | | Chest X-ray | | N/A | Assesses lung condition, abnormal results may mean pneumonia or other issues | ## Patient Report (information received in report): **ROOM:** 124 **INITIALS:** A.W **TEAM/PHYSICIAN:** Dr. Noha Abdelhamid **DX:** Acute Diastolic Heart Failure **HX:** Elevated troponin, shortness of breath, bilateral peripheral edema **ALLERGIES:** Excedrin **CODE:** Full **ISOLATION:** N/A **MONITOR:**Continous telemetry **O2:** Room air **ACCUCHECK:** q6h **DIET:** Cardiac diet **ACCESS/FLUIDS:** Peripheral IV in place **ROOM:** _ **INITIALS:** _ **TEAM/PHYSICIAN:** _ **DX:** _ **HX:** _ **ALLERGIES:** _ **CODE:** _ **ISOLATION:** _ **MONITOR:** _ **O2:** _ **ACCUCHECK:**_ **DIET:** _ **ACCESS/FLUIDS:** _ **OSTOMY:** None **N/G:** None **FEEDTUBE:** None **FOLEY:** None **WOUND/DRESSING/PRESSURE ULCER:** None **PREVIOUS SHIFT:** Patients background: Worsening of SOB, low potassium, and no drastic improvements for the peripheral edema. Blood pressure slightly elevated; mild tachycardia, stable SPO2. Patient's labs showed elevated BUN and elevated creatinine, indicating renal strain; low potassium but was corrected with recent supplementation. Reduced respiratory stress due to oxygen therapy, and shortness of breath has improved. Patient exhibits some anxiety due to alcohol withdrawal, with is wife concerned and visiting frequently. Administered Furosemide as part of fluid management, potassium supplements for hypokalemia, with the rest of scheduled medications. **PENDINGS:** * Withdrawal Monitoring: watch for signs of agitation, increased anxiety. tremors * Troponin levels: Await updated results to assess cardiac status **MY SHIFT:** **Assessments:** * 7:30 am: Rechecking vital signs every 4 hours. Performed focused cardiac assessment to check heart sounds. Patient has elevated heart rate and regular rhythm. S3 heart sounds present, peripheral pulses are slightly diminished with +2 pitting edema in lower extremities. * 11:30 am: Diuretic therapy showed patial effectiveness with slight reduction in edema. closely monitored for early signs of alcohol withdrawal, including hourly checks for changes. **OSTOMY:** _ **FEEDTUBE:** _ **N/G:** _ **FOLEY:** _ **WOUND/DRESSING/PRESSURE ULCER:** _ **PREVIOUS SHIFT:** _ **PENDINGS:** _ **MY SHIFT:** **D** ## On your Clinical Day- YOUR HEAD-TOE assessment- Focus Assessment if can not do the Head to Toe assessment. ### HINT-ABNORMALS should result in a NURSING DIAGNOSIS ON THE NURSING DIAGNOSIS LIST **ID band present and correct?** yes **CODE STATUS (from Chart)** Full Code **A Problem is anything ABNORMAL or that requires intervention.** **CNS (Neurological):** * **Orientated to time** ✗ * **place** ✗ * **person** ✗ * **Glasgow Coma Scale:** 13/15 * **Pupils:** PERRLA? Reactive * **Size:** 3 mm * **Muscle strength:** symmetrical bilateral +5 * **Speech:** clear and appropriate * **Fall risk:** Yes * **ADLs (independent, dependent etc):** dependent * **Sleeping pattern:** consistent * **Pain Assessment:** (level, location, interventions) Denied pain * **Any problems?:** Problems with some SOB **CVS (Cardiovascular):** * **HR:** 95 * **BP:** 90 * **RR:** 20 * **Temp:** 97.9 * **Pulses:** Radial present * **Pedal:** slight pedal pulse * **Heart sounds:** S3 heart sounds present * **Neck veins (JVD):** present * **DVT prevention:** No Dvt * **Edema:** edema on left and right lower extremities * **Cap Refill time:** less than 2 sec * **Telemetry:** Normal regular sinus rhythm * **ECG strip:** _ * **Lead:** 2 * **Atrial/ventricular rate:** 95 * **Regular/irregular:** regular * **PR interval:** 0.16 * **QRS interval:** 0.08 * **ECG interpretation:** normal sinus rhythm **WE WILL HELP YOU HERE.** (attach the ECG strip to analyze above, here. Staple or tape it in place. NO NAMES or other identifying information left on strip). ## IV lines: State location and if peripheral or central. IV Solution and rate. 1. right antecubital IV and restricted as per physicians orders **Any problems:** no problems ## RESPIRATORY: * **Oxygen Delivery:** Room air: X * **Nasal cannula:** * **Facemask:** * **Respiratory rate:** 20 * **Other:** _ * **O2 saturation:** 95% * **Lungs sounds:** crackles noted bilaterally at the bases * **Needing suctioning?:** no * **Incentive Spiromenter?:** n/a * **Sputum?:** no sputum * **Chest physio?** n/a **Any problems:** only problems with shortness of breath ## GI: * **Diet:** cardiac diet * **Accuchecks:** no significant issue * **Last BM:** 10/31 * **Bowel sounds:** normal and reactive * **Feeding tube(type and location):** _ * **Abdomen assessment?** soft and non tender, no distension **Any drains or tubes?** no tubes or drains **Any problems?** no problems ## GU: * **Dialysis Patient?(check shunt)** n/a * **Foley:** no * **Urine color/clarity:** yellow and clear * **Intake:** 500 mL * **Output:** 250 mL * **Balance for your shift:** +240 mL **Any problems?** no problems ## SKIN: * **Color:** normal * **Warmth:** warm * **Dry/sweating:** dry * **Capillary refill ?** less than 2 * **Any wounds?** No wounds * **Wound treatments?** N/A * **Any new red areas?** N/A ## PSYCHOSOCIAL: * **Any visitors today?** yes * **His wife** * **Any issues?** Wife expressed concern for his long-term health and the potential impact of his alcohol abuse on his heart failure management. ## TEACHING: Did you do any? **What did you teach about?** To manage your heart failure, monitor symptoms like swelling and shortness of breath, take your medications as prescribed, and limit sodium and fluid intake. Eat a balanced diet and stay active with light exercise. Avoid alcohol, as it can worsen your condition. Track your weight daily and contact your HCP if symptoms worsen.