Nursing Care Plan
NR 340 – Clinical Assessment Guide with NCP Organizer
Student Name ____CP_____________________ Date _2/12/13_____ Pt Initials _MK_____
Medical Diagnosis
#1: Multiple coronary artery disease
Chief Complaint
#1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13
on day of Admission
Chief Complaint
#1 Use Quotes: “Pain 8/10”
on day of your nursing care
Prior Illnesses
Hypertension, coronary artery disease, obesity, angina
Family History
Father passed away from a heart attack; Mother had a stroke
General Survey
Sex M
Race Caucasian
Age 74
Height 175cm
Weight 90.7 kg
Facial Expression/Contour/Symmetry symmetrical, tired Speech normal Mental Status oriented
Level of Consciousness awake and alert to person, place, time
Physical Distress 8/10 Emotional Distress tired, happy
General Survey
in two – three sentences: Mr. K was admitted 2/6/13 with complaint of SOB on exertion with angina.
Multiple coronary artery disease discovered from L heart catherization. CABG x4 on 2/11/13 w/ use of L internal mammary artery to L anterior descending, reverse saphenous vein graft to the obtuse marginal, reserve saphenous vein graft to R posterior descending artery and R posterior arterial branch; epiciortic sonography; ligation of L atrial appendage. Today patient is stable, awake, oriented, and in high spirits; medicated for pain, mediastinal tubes removed 2/12/13.
Vital Signs
Time 9am
BP 110/95
P 98
R 18
Temp 100.1 F; oral
Cardiovascular System:
1. Skin:
-color: normal
-temperature: warm and dry to touch
-turgor: present
-diaphoresis: mild around forehead
-dryness: none
2. Pulses (radial, pedal, apical):
-rate: 98
-regularity: rhythm afib; epicardial pacemaker
-equality: bilateral radial and pedal pulse; palpable
-presence: all pulses present and palpable; S1 and S2 present; Doppler signal available to all
-absence: none
3. Neck Veins:
-distention: present
Student Name ____CP_____________________ Date _2/12/13_____ Pt Initials _MK_____
Medical Diagnosis
#1: Multiple coronary artery disease
Chief Complaint
#1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13
on day of Admission
Chief Complaint
#1 Use Quotes: “Pain 8/10”
on day of your nursing care
Prior Illnesses
Hypertension, coronary artery disease, obesity, angina
Family History
Father passed away from a heart attack; Mother had a stroke
General Survey
Sex M
Race Caucasian
Age 74
Height 175cm
Weight 90.7 kg
Facial Expression/Contour/Symmetry symmetrical, tired Speech normal Mental Status oriented
Level of Consciousness awake and alert to person, place, time
Physical Distress 8/10 Emotional Distress tired, happy
General Survey
in two – three sentences: Mr. K was admitted 2/6/13 with complaint of SOB on exertion with angina.
Multiple coronary artery disease discovered from L heart catherization. CABG x4 on 2/11/13 w/ use of L internal mammary artery to L anterior descending, reverse saphenous vein graft to the obtuse marginal, reserve saphenous vein graft to R posterior descending artery and R posterior arterial branch; epiciortic sonography; ligation of L atrial appendage. Today patient is stable, awake, oriented, and in high spirits; medicated for pain, mediastinal tubes removed 2/12/13.
Vital Signs
Time 9am
BP 110/95
P 98
R 18
Temp 100.1 F; oral
Cardiovascular System:
1. Skin:
-color: normal
-temperature: warm and dry to touch
-turgor: present
-diaphoresis: mild around forehead
-dryness: none
2. Pulses (radial, pedal, apical):
-rate: 98
-regularity: rhythm afib; epicardial pacemaker
-equality: bilateral radial and pedal pulse; palpable
-presence: all pulses present and palpable; S1 and S2 present; Doppler signal available to all
-absence: none
3. Neck Veins:
-distention: present
References: Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier. Ignatavicius, D., & Workman, D. (2012). Medical surgical nursing. (7 ed., pp. 828-829). St. Louis Missouri: Elsevier. Skidmore-Roth, L. (2012). Mosby’s nursing drug reference. (25 ed.). St.Louis, MO: Mosby.