UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

FUNDAMENTAL PATIENT ASSESSMENT TOOL Student: Nicki Shaw

Assignment Date: 07/14/2016
.
Agency: MPM
 1 PATIENT INFORMATION
Patient Initials: XX Age: 55 Admission Date: 07/13/2016
Gender: Male Marital Status: Married Primary Medical Diagnosis:
Primary Language: English Chronic atrial fibrillation
Level of Education: Bachelor’s Degree Other Medical Diagnoses: (new on this admission)
Occupation (if retired, what from?): Construction Project Manager Symptomatic bradycardia
Number/ages children/siblings: One brother - 59 Paroxysmal supraventricular tachycardia
Three sisters – 61, 58, 57
Served/Veteran: No Code Status: Full code
If yes: Ever deployed? Yes or No N/A
Living Arrangements: Lives with wife Advanced Directives: No
If no, do they want to fill them out? Plans on it
Surgery Date: N/A Procedure: N/A
Culture/ Ethnicity /Nationality: American / Caucasian
Religion: Christian - Lutheran Type of Insurance: Medicare

 1 CHIEF COMPLAINT:
“Chest pain, weakness, passing out”

 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)

Patient reports feelings of “weakness” and “chest pain” and says he feels like “passing out”. These symptoms started
around ten days ago. Reports that his chest pain is “sharp/stabbing” and comes in “short spurts”. Reports unusual
feeling of bounding heart beat and discomfort in his chest. Before admission, patient was driving when he suddenly felt
dizzy and “out of it”. He reportedly went through a red light as a result of this. Upon urging from his wife, he brought
himself into the emergency room. EKG shows sinus rhythm with occasional atrial fibrillation and premature ventricular
contractions. Suspects some sort of problem from his beta-blocker. His beta-blocker dose was decreased upon
admission and he is being monitored for any effects of this medication adjustment.

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  2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date Operation or Illness
History of chronic atrial fibrillation
2000 Cardiac catheter ablation
2007 Cardiac catheter ablation
2008 Cardiac catheter ablation
2009 Mini maze surgical procedure
History of chronic back pain
2011 Three epidural steroid injections at L4
2013 Spinal fusion C4 – C5
2014 Spinal fusion L5 – S1

2

(angina, MI, DVT etc.)

Stomach Ulcers
Environmental

Mental Health
Age (in years)

FAMILY

Heart Trouble
Bleeds Easily

Hypertension
Cause
Alcoholism

MEDICAL

Glaucoma

Problems

Problems
Allergies

of

Diabetes
Arthritis

Seizures
Anemia

Asthma

Kidney
HISTORY
Cancer

Tumor
Stroke
Death

Gout
(if
applicable)
Father 84 N/A
Mother 85 N/A
Brother 59 N/A
Sister 61 N/A
Sister 58 N/A
Sister 57 N/A

Comments: Include age of onset

N/A

 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna) YES NO
Routine childhood vaccinations U
Routine adult vaccinations for military or federal service N/A
Adult Diphtheria (Date) U
Adult Tetanus (Date) Is within 10 years? 2014
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received

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 1 ALLERGIES
NAME of
OR ADVERSE Type of Reaction (describe explicitly)
Causative Agent
REACTIONS

NKDA
Medications

Medical Tape Skin irritation, hives

Other (food, tape,
latex, dye, etc.)
NKFA

 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)
With a primary diagnosis of chronic atrial fibrillation, this patient experienced irregular heartbeats resulting from
abnormal electrical impulses. The electrical activity behind atrial fibrillation is rapid and begins in an area other than the
SA node. Most often the impulse starts in the pulmonary veins (Markides and Schilling 2003). Common causes of atrial
fibrillation are thought to be abnormal heart structure, ischemic events, hypertension, and even genetics (Markides and
Schilling 2003). Because of the rapid contractions of the atria, ventricular rhythm also increases so blood is not pumped
effectively as the chambers are unable to completely fill. Diagnosis of this diseases is made by electrocardiogram
confirmation. Treatment is geared towards regulating abnormal heart rhythm. Medications used in atrial fibrillation
management include anti-hypertensives, like the patient’s prescription of atenolol. Beta-blockers are one example of how
to slow impulses traveling to the ventricles (Beers 2003). Although medication can be used to manage and control atrial
fibrillation, if normal rhythm cannot be achieved or maintained a cardiac ablation can interrupt conduction. A cardiac
ablation is a procedure in which radiofrequency energy is applied to the heart through a catheter (Beers 2003). This
patient underwent three of these procedures.

 5 MEDICATIONS: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if
given in last 48°). Give trade and generic name.]
Name atenolol (Tenormin) Concentration 25 mg/ tablet Dosage Amount 12.5 mg (0.5 tablet)
Route PO Frequency- Once daily
Pharmaceutical class Beta Blocker Home Hospital or Both
Indication – used to treat HTN and angina pectoris
Adverse/ Side effects – bradycardia, hypotension, fatigue, dizziness, nausea/vomiting
Nursing considerations/ Patient Teaching – nurses must monitor patient’s BP / teach patient not to discontinue medication
abruptly as rebound HTN, MI, angina, and ventricular arrhythmias may occur, teach patient to take his pulse to
monitor for bradycardia

Name enoxaparin (Lovenox) Concentration 40 mg/ 0.4 mL Dosage Amount 40 mg

Route SubQ Frequency - Once daily
Pharmaceutical class- Low molecular weight heparin Home Hospital or Both
Indication- used in addition to ASA to reduce risk of blood clots, standing order for pts on telemetry monitoring
Adverse/ Side effects - hemorrhage, anaphylaxis, thrombocytopenia, angioedema, nausea/vomiting
Nursing considerations/ Patient Teaching –nurses must monitor vital signs, take baseline clotting labs / teach patient to watch
for bleeding and bruising, notify provider before starting OTC or herbal therapies as these may affect anticoagulant
effect

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Name aspirin (Bayer) Concentration 325 mg/ tablet Dosage Amount 325 mg
Route PO Frequency Once daily
Pharmaceutical class – Salicylate Home Hospital or Both
Indication –to prevent clotting, to lower risk of ischemia and MI
Adverse/ Side effects – hepatotoxic, GI bleeding, thrombocytopenia, tinnitus/ototoxic, slow clotting, GI distress
Nursing considerations/ Patient Teaching – nurses need to check platelet labs for in long term ASA usage / teach patient to take
ASA with food to decrease GI problems, watch for bleeding and bruising, report signs of hearing loss or ringing

Name nitroglycerin (Nitrostat) Concentration 0.4 mg/ tablet Dosage Amount 0.4 mg
Route SL Frequency PRN
Pharmaceutical class Nitrate Home Hospital or Both
Indication – treat/prevent angina, lower oxygen demand of heart, prevent MI, standing order for pts on telemetry
Adverse/ Side effects – HA, dizziness, orthostatic hypotension, tachycardia, flushing, palpitations
Nursing considerations/ Patient Teaching – teach patient how to take sublingually, teach patient to seek medical help
immediately if chest pain doesn’t improve or end

Name ketorolac (Toradol) Concentration 15 mg / mL Dosage Amount 30 mg

Route IV Frequency - PRN Q6
Pharmaceutical class NSAID Home Hospital or Both
Indication – management of pain (pt has chronic back pain), standing order from doctor
Adverse/ Side effects - HA, arrhythmias, nephrotoxic, hepatotoxic, GI distress
Nursing considerations/ Patient Teaching – nurses need to monitor platelets / teach patient to not take other NSAIDs, teach
patient signs of GI bleeding (blood in vomit, urine, or stool)

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  5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Regular
Diet patient follows at home? Regular
24 HR average home diet:
Breakfast: 1 Quest Chocolate Chip Cookie Dough Protein
Bar, 12 oz black coffee
Lunch: Ten hot traditional drumstick chicken wings, 4
celery sticks, 2 tbsp ranch dressing, 32 oz unsweet iced tea
Dinner: Taco Salad – ¼ lb ground sirloin, ½ head of
Romaine lettuce, ¼ cup raw onion, 1 oz sour cream, ¼ cup
tomato paste, ¼ cup canned black beans
Snacks: ¼ cup dry-roasted, salted peanuts
Liquids (include alcohol): 16 fl oz tap water, 1 can Diet
Coke
Analysis of home diet (Compare to “My Plate” and
Consider co-morbidities and cultural considerations):
As the graph below shows, the majority of this patient’s
diet consists of protein and vegetables. This made sense as
he described himself as a “meat and potatoes” kind of guy.
He did not come close to meeting daily requirements for
dairy, grains, or fruits (SuperTracker 2016). Individualized
dietary goals for this patient would be starting a cardiac diet
and limiting his intake of processed foods that can be high
in sodium, saturated fat, and other elements detrimental to
his health.
Suggestions regarding his breakfast might include adding
items from other food groups to help balance his low daily
intake of fruit, dairy, and grain. Healthy alternatives would
include whole grain toast, fresh fruit, and a serving of dairy.
The patient stated he eats this out of convenience every
day. Teaching would include substituting fried foods with
healthier options such as grilled or baked and making
healthy choices even when eating out.
Recommendations to improve his average dinner would be
to occasionally replace red meat with a healthier option
such as poultry, seafood, or a plant-based protein. Large
amounts of red meat are not recommended in patients with
cardiovascular disease as they contain more cholesterol
than alternative protein sources. This may be indicated in
his increased LDL lab value.
His sodium intake was well over the recommended target.
Reading the nutrition facts on packaged foods may help
him stay clear of excess sodium in his diet.

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?
Wife
How do you generally cope with stress? or What do you do when you are upset?
Walks dogs or talks to wife

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No

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+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

 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs.
Inferiority Identity vs. Role Confusion/Diffusion 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 Erickson’s developmental stage for your
patient’s age group:
Generativity is best defined as involvement with one’s life and the people in it, while stagnation is the process of
becoming stagnant or unmoving. (Merriam Webster’s, 2003)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
He is fifty-five years old which would put him in the stage of generativity versus stagnation. Beyond just his age, he fits
into this category based on the way he spoke of his stepson and step-grandchildren. He has an active role as a parent
despite never having biological children and continues that role through his grandchildren. His actions best fit in the
generativity stage as he is involved in their lives and includes them in his. Stagnation would not be an accurate description
of his stage in life because he is not self-absorbed
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
His disease impacts this developmental stage of his life because of his impaired physical abilities. Obviously
hospitalizations impact his time with his family. This also might affect his role as a provider as his illness prevents him
from working. Despite all of this, the patient seems to be content with his current stage of life and had nothing negative to
say about it. He seems secure in his position as a step-parent, step-grandfather, and provider and does not seem to be set
back by his diagnosis.

+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?”
God’s will, genetics

What does your illness mean to you?

Had to quit smoking and drinking

+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? ____Never_____________________________________
Have you or a partner ever had an abnormal pap smear? __N/A_______________________________________________
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Have you or your partner received the Gardasil (HPV) vaccination? ____No_____________________________________

Are you currently sexually active? ______Yes__________________ If yes, are you in a monogamous relationship?
________Yes________ 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? ______11 years___________________________________________

Have any medical or surgical conditions changed your ability to have sexual activity? ____Yes – back pain ___________

Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
____” Keeps me grounded, Church on Sundays, means moderation of everything” _________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
____No__________________________________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No
If so, what? How much? (specify daily amount) For how many years? 29 years
Cigarettes 2 packs a day (age 16 thru 45 )

If applicable, when did the

Pack Years: 58 pack years
patient quit?
10 years ago – 2006 – 45 y.o.
Does anyone in the patient’s household smoke tobacco? If Has the patient ever tried to quit? Yes
so, what, and how much? If yes, what did they use to try to quit? Nothing
No

2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No
What? How much? “A lot” For how many years? 32 years
Beer, liquor Volume: N/A (age 18 thru 50 )
Frequency: Everyday
If applicable, when did the patient quit?
5 years ago – 2011 – 50 y.o.

3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No
If so, what?
Marijuana, cocaine How much? For how many years? 1980’s
“A lot” (age 18 thru 30 )

Is the patient currently using these drugs?

If not, when did he/she quit?
Yes No
1990’s

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No – project manager doesn’t have to wear hardhat or be exposed to dangerous equipment

5. For Veterans: Have you had any kind of service related exposure?
N/A

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 10 REVIEW OF SYSTEMS NARRATIVE

General Constitution (OLDCART anything checked above)

How do you view your overall health? “Pretty healthy, working on it”

Integumentary: Reports no problems with skin. Uses sunscreen when out in the sun, showers every day.
Denies lesions/sores.
HEENT: Reports blurry vision which he wears prescription contacts for all the time. Last eye exam 2015.
Schedules regular dentist appts every 6 months. Reports no changes in hearing.
Pulmonary: Denies difficulty breathing/chest pain. Unproductive cough occasionally. Pneumonia as a child in
the 1970’s.
Cardiovascular: Occasional chest pain, takes daily Aspirin as a “blood thinner”. High blood pressure runs in
his family but patient has never been diagnosed; is currently taking beta-blocker. Has had several surgeries to
fix his atrial flutter.
GI: BM every day, normal, “cast iron stomach”. Denies nausea/vomiting. Denies indigestion.
GU: Denies difficulty voiding. Reports no issues.
Women/Men Only: Reports no concerns. He plans on going in for a prostate exam soon.
Musculoskeletal: No numbness or tingling, no weakness. Suffers from chronic back pain. Had several surgeries
to relieve pain with no success. Opioid pain medicine used to treat pain for years but it made him feel “lousy” so
he stopped. Reports that he lives with the pain in his own way and is not looking for any treatment.
Immunologic: Reports only a minor skin allergy to tape, discovered on past hospital stay.
Hematologic/Oncologic: Denies any problems. Takes Aspirin daily to “thin the blood”.
Metabolic/Endocrine: Denies any problems.
Central Nervous System: Reports occasional headaches. Denies dizziness.
Mental Illness: Denies any mental health problems.
Childhood Diseases: Chickenpox at 8 years old. Pneumonia at 9 years old. Measles at 11 years old.

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.

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±10 PHYSICAL EXAMINATION:
General survey ___A & O x3___________________________________________________
Height ____6’ 1” ___Weight_280 lb__ BMI ___36.9_____ Pain (include rating and location) __0/10_____________
Pulse_64____ Blood Pressure (include location) _128/76 R upper R arm___Temperature (route taken) _97.4 oral__
Respirations__22________ SpO2 ___97% ___________ Room Air or O2___Room Air_________________
Overall Appearance_____Clean, symmetrical, maintains eye contact, clothes from home________________________
Overall Behavior____Appropriate, responsive, cooperative ______________________________
Speech___Clear, articulate, appropriate for age and situation_______________________________________________
Mood and Affect___Pleasant, humorous, engaging, talkative___________________________________
Integumentary__Skin - pink, dry, warm, elastic, free of lesions/wounds, no clubbing, cap refill < 3 seconds
IV Access__IV R FA_- clear, dry, intact, patent, no erythema or pain___________________________
HEENT___Normocephalic, PERRLA intact, mucous membranes-pink, moist, free of lesions, wears contact lenses, ears
symmetrical, no discharge, symmetrical smile, white teeth_______________
Pulmonary/Thorax Clear to bases bilaterally, no adventitious sounds, unlabored effort__________________
Cardiovascular_S1 and S2 auscultated, no adventitious sounds, no thrills, 2+ pulses x4 extremities
GI__Round, no tenderness or guarding, normoactive bowel sounds x 4 quadrants, last BM 7/13/16_normal_________
GU__Reports regular voiding pattern, last void 7/14 (today) _____________________________________________
Musculoskeletal 5/5 strength x4 extremities, 100% ROM x4 extremities, sensation intact____________
Neurological Intact, A & O x3, PERRLA intact, sensation intact

±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 Dates Trend Analysis

RBC 4.83 07/13/2016 N/A Within normal range
(4.7-6.1 million cells/L)
PLT 212 07/13/2016 N/A Within normal range
(150 – 450 billion/L)
-Should be monitored while
on Lovenox and ASA as
these may decrease PLTs
WBC 5.4 07/13/2016 N/A Within normal range
(3.5-10.5 billion cells/L)
-Long term ASA may
decrease WBC count
INR 0.9 07/13/2016 N/A Within normal range
(0.8-1.2)
-Should be monitored while
on Lovenox to measure
time it takes patient to clot
LDL 107 07/13/2016 N/A Slightly above optimal
values
(<100 mg/dl – optimal)
-Measures “bad” cholesterol
-Risk for heart disease

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EKG (electrocardiogram) upon admission - EKG showed sinus rhythm with occasional premature
ventricular contractions and atrial fibrillation. This diagnostic test was most likely done on this patient
because he has a history of chronic atrial fibrillation and presented to the emergency room with chest pain.

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

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

-Medication adjustment – monitoring effect of lowered beta-blocker dose, taking vitals Q12, B/P Q6
-Random accucheck upon admission – glucose level of 100
-Telemetry monitoring – continuously, patient has hx of atrial fibrillation and was admitted with chest pain
-Regular activity order – independent, no assistance necessary
-Regular diet order

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

1.
Imbalanced nutrition r/t poor diet, lack of exercise aeb BMI 36.9, weight 280 pounds, nutrition analysis

2.
Risk for CVD r/ poor diet, obesity, family hx of HTN, chronic afib

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± 15 CARE PLAN
Nursing Diagnosis: Imbalanced nutrition r/t poor diet, lack of exercise aeb BMI 36.9, weight 280 lbs, high LDL
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Will eat at least one cup of fruit Will provide U.S. Dietary Client’s daily fruit intake was Patient will order and consume
by the end of shift. Guidelines to patient. Will assist nonexistent. Fruit is important more fruits during meal time.
client in ordering fruits during because it contains vitamins and
mealtime. minerals that are beneficial to the
body (Ackley and Ladwig 2014)
2. Will increase whole grain intake Educate patient on resources Food trackers allow patients to see Meals ordered during hospital stay
to over 3 grams a day during available online such as the food the big picture of their diet and will include whole grain foods.
hospital stay. and exercise trackers on internet. help plan further improvement Track fiber intake.
Teach about whole grain (Ackley and Ladwig 2014)
alternatives to popular processed
wheat products.
3. Will decrease intake of red meat Include dietary consult and Patient currently eats large Monitor weight loss, BMI trend,
to less than after discharge. intervention before discharge. amounts of red meat and processed laboratory values, overall health
Encourage use of online resources meat. These are both linked as risks status at follow up appointments.
and information such as Super for CVD and cancer (Ackley and
Tracker. Ladwig 2014)

Nursing Diagnosis: Risk for CVD r/t poor diet, obesity, family hx of HTN, chronic afib
Patient Goals/Outcomes Nursing Interventions to Achieve Rationale for Interventions Evaluation of Goal on Day Care
Goal Provide References is Provided
1. Will decrease cholesterol intake Help client order meals. Teach Cholesterol contributes to Patient will replace saturated fats
to <300 mg a day during hospital about healthy alternatives to atherosclerosis, or the build-up of with unsaturated oils. Will
stay. saturated fats. Provide information plaque in the cardiovascular system supplement current diet choices
about U.S. Dietary Guidelines. (Ackley and Ladwig 2014) with low-fat replacements.
2. Will increase fiber intake to at Teach client benefits of an High-fiber foods help decrease Will consume over 38 grams of
least 38 grams daily. increased fiber intake. Suggest LDL cholesterol and improve fiber. Monitor meal orders. Patient
food such as beans, whole grains, digestion (Ackley and Ladwig will teach back benefits of fiber.
and fruits. 2014)
3. Will increase daily exercise to at Assist client in planning ways to Reduces body weight and risk for Evaluate weight loss, patient
least 30 minutes a day during incorporate activity into his daily CVD. Increases circulation compliance, and testimony.
hospitalization and after discharge. schedule. Suggest step tracker or (Ackley and Ladwig 2014)
discuss gym membership.
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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 patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care

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 References

Beers, M. H. (2003). The Merck manual of medical information. Whitehouse Station, NJ: Merck &. Co.

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, Mo:

Elsevier.

Markides, V., & Schilling, R. J. (2003, August). Atrial fibrillation: Classification, pathophysiology, mechanisms and drug treatment. Retrieved July

27, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767799/

Merriam-Webster's collegiate dictionary (11th ed.).(2003). Springfield, MA: Merriam-Webster.

SuperTracker: My Foods. My Fitness. My Health. (n.d.). Retrieved July 26, 2016, from https://supertracker.usda.gov/

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