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Nursing Care Plan
ASSOCIATE NURSING PROGRAM Student Name: ___Blanca Suarez________ Date: 10/23/2012
Initial: J. Gonzalez Sex: M / F Date of Admission: 10/23 /2012
Instructor: ___Adria Diaz________ Clinical Site: ____Palmetto Hospital_______ Hospital_______
Patient Information DOB: 10/01/1947 Age: 65 Ethnic Group: White / AA / Hispanic / Asian Allergy: PCN HGT: 5’7 Weight: 220 lbs. Diet: NAS, low fat, regular
Admitting Diagnoses: 1) Congestive Heart Failure- CHF 2) Coronary Artery Disease- CAD 3) Acute decompensated heart failure- ADHF 4) Hypertension- HTN Past Medical History: Immunizations: influenza virus 10/01/2012, Tuberculosis 10/01/2012.
NKA. Hospitalizations: His medical history includes coronary artery disease x 10 years. He had a balloon angioplasty in 2000 and an M.I. in 1988. . CAD x 10 years. CHF x 5 years. MI 1990. This is his third admission for CHF since his diagnosis five years ago. Experienced an allergy to Penicillin; experienced rash and hives in 1985.
Past Surgical History: Balloon Angioplasty (1 vessel) 10/2000 Status Post Cholycystectomy 1990 Status Post Appendectomy 1985 Status Post open repair and internal fixation of left femur fracture, 1983
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Social History: Retired accountant, college educational level, lives with eldest daughter E. Gonzalez, Hispanic, Catholic. He is hearing impaired and wears bilateral hearing aids. He wears glasses and reads with some difficulty. 2 PPD x 40 years. Quit 1995. Denies ETOH, drug use. hypertension, but Family history: Mother 79, deceased of CAD. Father 54, deceased, heart attack. No brothers or sisters. There is a positive family history of hypertension, no diabetes, or cancer.
History of Present Illness: J.G. was admitted with a diagnosis of chronic congestive heart failure (CHF) with acute exacerbation and Acute decompensated heart failure (ADHF). Client became fatigued and presented to E.R. with increased SOB and dyspnea on exertion (DOE) c/o increasing fatigue and severe shortness of breath (SOB), orthopnea Sleeps with 3 pillows. Lower extremity edema.
Objective Finding
Admission Vital Sign: Sign: BP: 176/96
HR: 103 Rhythm- Iregular S1-s2 mild heart murmur HR: 89
Current Vital Sign: BP: 160/80 Laboratory Studies: CBC Metabolic Panel WBC 5,000-10,000/ mm3 RBCs 4.2-6.1 x 106/μ 106/μg Hgb 11.5-17.5 g/dl Hct 40-52%
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Na+ 160 mEq/L K+ 3.3 mEq/L CL-- 102 mEq/L Ca+ 9.1 mg/ dl Serum albumin 2.8 g/dl Glucose 99 mg/dl Serum digoxin level 2.6 ng/dl Bun 30 mg/dl Cr 0.6 mg/dl Sodium 138 mEq/L Cloride 102 mEq/L Potassium 3.3 mEq/L Calcium 9.1 mg/dL Cholesterol <260 mg/dL
RR: 22
RR: 21
Temp: 98.6 Taken Oral route Temp: 98.5
Coagulation
Lipid Profile
Other: ( U/A, U/A, ABG’s, Protombin , etc)
PT PTT
LDL 160-189 mg/dL HDL 60 mg/dL Cholesterol total 260 mg/dl Triglycerides Triglycerid es 180 mg/dl
Digoxin level 2.6 ng/mL Dilantin level 18 ug/mL Arterial PH 7.20 pCO2 30 mm Hg PO2 80% PaO2: 70 mm Hg HCO3: 21% mEq/l SaO2: 90%
11 secs 65 secs
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Imaging Result: (X-Ray, CT scan, MRI, MRCP, ultrasound …….) …….) 10/01/2012- Chest x--ray--mild left ventricular hypertrophy; pulmonary congestion resolving. 07/01/2012- ECG- observable CAD, acute myocardial ischemia, left ventricular hypertrophy, conduction defects and dysrthymias. 06/01/2012- Left ventriculography- decreased LV function
Endoscopic Result: (colonoscopy, EGD…..) Endoscopic ultrasound (EUS) 07/01/2005 07/01/2005 yielding positive results for swollen/inflamed appendix. Laparoscopy related to appendectomy, 07/01/2005: 07/01/2005: There is no blood in the abdomen, no hernias, no intestinal obstruction, and no cancer in any visible organs. The liver is normal.
Physical Assessment findings HEENT: Oxygenation/breathing: labored breathing, moderate respiratory distress uses 3 pillows at night, c/o increased fatigue & SOB, crackles L base, wheezes, Oxygenation/breathing: decreased breath sounds. General appearance- admitted in moderate respiratory distress. distress. Circulation: S1, S2, Mild heart murmur, murmur, decreased elevated BP, dysrythmia. Capillary refill: Prolonged >3 secs. Pink nail bed color. Edema: Bilat. Ankle +2 pitting. Pacemaker: N/A. Homan’s Sign: Sign: Negative. Level of ound; R eactive eactive to Light consciousness: Awake, alert Oriented x 4 (time, place, person, event). Behavior Behavior:: Cooperative, anxious. PEERLA: Pupils Equal and R ound; and Accommodation, night vision visual difficulty, Hx of cataracts, visual loss, dry burning sensation in eyes, trouble reading. Conjunctiva & sclera moist, glossy, visible small blood vessels, yellow fat deposits under lids. Lacrimal gland, Lacrimal sac, Nasolacrimal duct No edema or tenderness over the lacrimal gland and no lashes: intact, no redness, no discharge, swelling or lesions, lashes evenly distributed and curve outward. Ears: external canal, tympanic tearing. Eyelids and lashes: membrane: shiny, shiny, translucent, pearly gray. The ear lobes are bean shaped, parallel, and symmetrical, symmetrical, the upper connection of the ear lobe is parallel with the outer cantus of the eye. No lesions noted on inspection, skin is same in color as in the complexion. The auricles firm cartilage on palpa tion. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection, no discharges or lesions. Nose: Symmetric and straigh straight, t, no flaring, uniform in color, air moves freely as the clients breathes throug through h the nares. Nasal Cavity: Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness. Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas. Trachea is midline and thyroid gland is normal without masses. Oral mucosa/tongue: pale, dry. Dentures Mouth: Symmetrical, pale lips, light pink gums and able to purse lips. Gag reflex: Present which is elicited through the use of a tongue depressor. Gastrointestinal: No complaints complaints of dysphagia, dysphagia, nausea, nausea, vomiting, vomiting, or change in stool pattern, consistency, or color. He complains of epigastric pain, burning in quality, approximately twice a month, which he notices primarily at night. Genitourinary: No complaints complaints of dysuria, dysuria, nocturia, nocturia, polyuria, or or hematuria. Abdomen: The abdomen is symmetrical with mild distention; bowel sounds are normal in quality and intensity in some areas; a bruit is heard in the right paraumbilical area. No masses or splenomegaly are noted; liver span is 8 cm by percussion. Extremities: mild cyanosis, no clubbing, mild edema are noted in lower extremities. Peripheral pulses in the the femoral, popliteal, popliteal, anterior anterior tibial, dorsalis dorsalis pedis, brachial, pedis, brachial, and radial areas are irregular. irregular. Nodes: No palpable palpable nodes in the the cervical, supraclavicular, supraclavicular, axillary or inguinal areas.
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Medication List Medication/Order Dose Digoxin
Lasix
Nitro--Bid (Nitroglycerin) Vasodilator Vasodilator (Nitrate) Metamucil (Psyllium)
KCl Potassium supplement
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Indication
Usual Dose
Increase cardiac output
QD 0.25 mg
Decrease edema and blood pressure
PO BID 40 mg
Prevent chest pain; increase cardiac output Dilates Coronary arteries; decreases preload and afterload afterload Prevent Constipation. Constipation. Bulk — forming forming laxative
2.5 mgs. P.O. QID
Replace Potassium Needed for Transmission of nerve impulses and cardiac contraction
20 mEq P. O. BID
15 ml P. O. qHs
Side effects Headache, dysrhythmias, hypotension, AV block, blurred vision, yellow--green halos, Circulatory collapse, loss of hearing, hypokalemia, Hypochloremic alkalosis hyperglycemia, hyperglycemia, nausea, polyuria, renal renal failure, thrombocytopenia, thrombocytopenia, anemia, rash pruritis, Postural hypotension, collapse, HA, flushing, dizziness N/V, anorexia, diarrhea, cramps
Cardiac depression, dysrhythmias, dysrhythmias, arrest, peak T waves, low R & RST, prolonged PR interval, wide wide QRS
Nursing Intervention Apical pulse 1 minute. Hold P < 60. Assess lytes, BUN/Cr, ALT, AST, H&H. I & O, daily wts, dig level. Assess client for s/s dehydration. adm in a.m. K+ replacement if < 3.0. adm. With food if nauseated.
Assess BP, pulse, pain. May develop tolerance. Adm. with 8 oz. H20 on empty stomach, 1 hr. before or 2 hrs. after Assess then adm. alone for better absorption. absorption. Give with 8 ozs of H20 followed by 8 oz. fluid Assess EKG, K+ level, I & after meal. Do not give IM or SQ powder, dissolve in 8 oz. cold water/juice
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Nursing Care Plan Once evaluated patient’s past and present history, select at least three nursing diagnoses from highest to lowest priority . Give nursing interventions (dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses .
Nursing Diagnoses
Desired Outcome
Nursing Interventions / Rationales
(.related to...secondary to...secondary to .evidenced by…..)
ND1) Breathing Breathing Pattern, Ineffective Ineffective Gas Exchange, Impaired
ND2) Fluid volume excess excess as evidenced evidenced by edema. Dyspnea on exertion (DOE): c/o shortness of breath with mild exertion.
ND3) Decreased Decreased cardiac output. output. Ineffective tissue Perfusion, as evidenced by edema in extremities. extremities.
NURSING CARE PLAN
Short term goal: Within 30 min. of treatment/intervention, patient has adequate gas exchange, as evidenced by normal breath sounds and skin color, HR 100 bpm or less, Pao2 80 mm Hg or higher, and Paco2, 45 mm Hg or less
Interventions: 1) Dependant interventions: Administer medications and assess the medication effects. Independent intervention: Assess patient’s: Assess patient’s: intake and output; output; weight; weight; lung sounds; vital signs; skin turgor and mucous membranes. Assess patient for JVD, edema and signs/symptoms of fluid overload. Monitor oximetry and ABG values and report significant findings. Rationale: oximetry of 92% or less and the presence of hypoxemia hypoxemia (decreased Pao2) and hypercapnia (increased Paco2) signify decreased oxygenation. The presence of crackles may signify alveolar fluid congestion and systolic dysfunction (left sided) heart failure. Decreased breath sounds signify fluid overload or decreased ventilation. ventilation.
Explain measures that can be taken to treat or prevent excess fluid volume by discharge. Demonstrate adequate tissue perfusion until until discharge discharge . Short term goal: Lungs clear to auscultation by time of Discharge
Independent interventions: 2) Assess lungs sounds q 4 hrs Count apical pulse rate q 4 hrs Assist patient into high fowlers position with the HOB up 90 degrees. Rationale: Reduce workload of heart; increase the force and efficiency of myocardial contraction. These anatomical positions facilitate ease of breathing & promote rest. This position position decreases work of breathing, breathing, reduces reduces cardiac workload, workload, and prompts gas exchange. These are signs of increasing respiratory distress that require prompt intervention. intervention.
Short term goal: Describe symptoms that indicate the need to consult with health care provider by the end of the AM assessment. By the end of the AM assessment, patient will identify
3) Independent intervention: Assess general appearance for weakness, fatigue, edema q shift and prn. Keep head of bed elevated Monitor fluid intake, restrict sodium intake as ordered. Monitor Lab work; K+, NA, BUN, Creatinine Teach patient about medications and activity restrictions. Teach the importance of fluid and sodium restrictions.
Keep the client warm and have the client wear socks and shoes when
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changes in lifestyle needed to increase tissue perfusion. Long term goal: Client will have Adequate cardiac output Client will be able to perform/resume perform/resume ADL without without increased exertion.
NURSING CARE PLAN
mobile. DO NOT apply heat Maintains vasodilation and blood supply. Heat can damage ischemic tissues Rationale: These s/s develop as the heart attempts to compensate for a decreased C.O. w/ resultant decrease in O2 supply to body’s tissues . Reduce workload of heart; increase the force & efficiency of myocardial contraction & eliminate the excessive accumulation of body water by avoiding excess fluid intake; Controlling the diet & monitoring diuretic and angiotensin. Fluid restriction will reduce myocardial workload and sodium restriction will promote excretion of excess fluid. Educate client on the importance of healthy diet in order to keep healthy weight, eat healthy foods like fruits & vegetables, client will be able to reduce BMI, & increase C/O & be more resistant to perform ADL.
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Evaluation (To be completed by faculty only)
Collection of Patient Information: __________________ __________________ (25%) Collection of Patient’s Objective Finding:____________________ (25%) Care Plan Development: ___________________ (50%) Comments:
FINAL GRADE: __________________________ (100%)
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