Westchester Community College
AND
Nursing Assessment
Student’s Name:
Date of care:
Client’s Initials: Gender: F Age: 77_ HT: _160cm (5’3”) Weight:73.4kg(161.1lbs)
Admitting diagnosis:
AAA/AVR
_
Textbook definition of the admitting diagnosis:(cite sources)
Abdominal Aortic Aneurysm/Aortic valve rupture (AAA/AVR) - aortic aneurysm is a balloon-like
bulge in the aorta, the large artery that carries blood from the heart through the chest and
torso. Aortic aneurysms can dissect or rupture: The force of blood pumping can split the layers
of the artery wall, allowing blood to leak in between them. This process is called a dissection.
The aneurysm can burst completely, causing bleeding inside the body. This is called a rupture.
Dissections and ruptures are the cause of most deaths from aortic aneurysms.
CITE SOURCE https://www.cdc.gov/heartdisease/aortic_aneurysm.htm
History of present illness:
Patient was presented to new Rochelle ED w/slurred speech, back pain radiating to LLE. New
Rochelle ED found type A dissection, transferred to MMC Moses ED on 09/19/2022. Patient
underwent type A dissection repair, aortic root and arch replaced, reimplantation of coronary
buttons, aortic valve repair 09/19/2022
Past medical history (include dates)
Hypertension (Diagnosis date unknown)
Right shoulder weakness (r/t motor vehicle accident several yrs ago)
Past present surgeries-text book definition of surgery: Dates:
Right shoulder surgery (several yrs. ago)
Type A dissection repair 09/19/2022 – Definition: Type A involves the ascending aorta,
regardless of the site of the primary intimal tear. Type A dissection is defined as a dissection
proximal to the brachiocephalic artery.
Site work: https://www.ncbi.nlm.nih.gov/books/NBK441963/
List All medication taken before admission:
Patient States “I wasn’t taking medication before this”
Current medications see attached sheet.
Nurses Notes:
10/13/2022 0845 BP:135/82 Pulse:91 O2 sat:98% Temp:98.7 Resp:17 Pain:1 Patient wellnourished adult female age 77 sitting in bed reading a book. Was alert, Oriented x3, and
cooperative. Nasal cannula receiving continuous oxygen 2L 28% FIO@ 24/7. Becomes winded
while speaking causing gaps in audible dialect. When asked how she ended up at burke she
stated, “I was sitting in my living room reading a book and my son said I stood up started
mumbling and then collapsed.” Smokes 3 cigarettes a day for 60yrs. Lives at home w/son in
single family home. No pain or discomfort during interaction states pain scale of 1 dull aching in
lower lumbar region. Pain improved w/ repositioning and transdermal lidocaine patch
application. Requires 1 person assist to ambulate and pivot to WC. Precautions: FALL RISK,
DYSPHAGIA, only thick liquids until reevaluated w/ modified swallow study. Must perform oral
hygiene after every meal to aid in prevention of pneumonia. Limited ROM in RUE due to MVA.
Becomes tired quickly needs assistance with ADL’s. Transported to elevator @0830 to PT
appointment. Picked up @0930 transported back to room. Moved from WC to bed appeared
comfortable in bed was alert, good physical & mental state.
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