Name: __________________________________________________
Data Collection:
Patient History
1. What is the relationship of the patient’s past medical history and his current medications? Answer a. and b. and c. below. (3 points each = 12 pts total)
a. List the medication’s therapeutic classification that is appropriate to the condition from the patient’s medical history.
b. Describe the therapeutic action of the medication (e.g. this medications blocks calcium and allows vasodilation). Use your own words.
c.. Of the medications listed in the right hand column, identify the condition(s) that it is treating from the list on the left column. There may be more than one answer. (In other words, why is this patient taking this medication?)
| Past Medical History for Mr. Hart:
Hypertension
Heart Failure
Hyperlipidemia
Myocardial infarction
Coronary Artery Disease
|
Home Medications:
simvastatin/Zocor 20 mg po daily a.
b.
c.
lisinopril/Prinivil 10 mg po daily a.
b.
c.
acetylsalicyclic acid 81 mg po daily
a.
b.
c.
eplerenone/Inspra 25 mg po daily a.
b.
c.
|
Data Collection:
Patient’s Symptoms and Diagnostic Tests
2. What is the relationship between this patient’s primary symptoms and his identified problem of heart failure?
(Review pathophysiology and how it influences the patient’s symptoms. Explain what is happening physiologically to this patient and how it is resulting in his symptoms. Be specific and complete.) (a. 2 points & b. 2 points = 4 pts total)
| Primary Symptoms:
a. Has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He is now becoming SOB at rest, experiencing chest pain with exertion, and is more fatigued and occasionally dizzy.
b. Has had difficulty getting his shoes on the last month because of increased swelling around his ankles. His weight has increased from 255 lbs. to 264 lbs. over the last 7 days.
|
Pathophysiology / relationship to primary symptoms:
a.
b.
|
3. What is the relationship between this patient’s relevant vital signs and the identified primary problem of heart failure? (a. and b.: 3 points each = 6 points total).
| Relevant Vital Signs:
a. Heart rate and character What is normal:
The patient’s data (rate, character):
b. Respirations: Rate and lung sounds What is normal: Rate:
Sounds:
The patient’s data: Rate:
Sounds:
|
Relationship to Heart Failure:
(What is causing the abnormality in this patient? Or is it normal?)
a.
b.
|
4. What is the relationship between this patient’s diagnostic tests and his identified primary problem of heart failure? (a., b., & c. = 3 points each and d. 2 points = 11 total pts)
| Diagnostic test results:
a. BNP
What is normal:
The patient’s data:
b. Ejection fraction
What is normal:
The patient’s data:
c. Troponins What is normal:
The patient’s data:
d. Electrocardiogram
The patient’s data (identify the rhythm):
|
Relationship to primary problem of Heart Failure or to the patient’s symptoms:
(Why were these tests ordered? What do the tests reveal about this patient’s condition? What do the tests mean for this patient?)
a.
b.
c.
d. |
Diagnosis/ Identifying the problem
5. Based on the data collection findings, the primary medical diagnosis for Mr. Hart is:
· An exacerbation of heart failure
What is the primary Nursing Diagnosis or the primary physiological problem for this patient?
________________________________________________________________________
Interventions
6. What is the relationship between the healthcare provider’s prescriptions and the patient’s primary problem of heart failure? (a.- f., 2 points each = 12 pts)
(How do these treatments impact this patient at a physiological level to help resolve his heart failure or its symptoms?)
| HCP Prescription:
a. Daily weights, I & O, anti-embolism stockings, fluid restriction
b. Oxygen therapy
c. Sodium, potassium, fat, and cholesterol restriction
d. The daily dose of eplerenone/Inspra
e. The one time increased dose of furosemide/Lasix
f. The consult for possible cardioversion
|
How it helps resolve primary problems associated with Heart Failure:
a.
b.
c.
d.
e.
f. |
Evaluation
(4 points, a.-d, 1 point each)
7. The patient is stabilized and ready for discharge.
Explain the classification, purpose, and intended therapeutic effect of adding warfarin/Coumadin to Mr. Hart’s medications: (2 points)
a. Classification of warfarin and its purpose for Mr. Hart:
b. In reviewing Mr. Hart’s medications, what should be brought to the attention of the HCP?
Evaluation, cont.
In applying the professional concept of Evidence-based Care, explain what follow-up activities and observations need to be addressed to promote health and wellness for Mr. Hart, even with his chronic condition of heart failure.
Be specific and complete, citing at least 2 actions. (2 points).
c.
d.
Adapted with permission from© 2011 Keith Rischer/www.KeithRN.com
