Professional Documents
Culture Documents
COLLEGE OF NURSING
Student: Narjess Yazback
Gender:
Female
1 CHIEF COMPLAINT:
Patient states that the reason they sought help is because I was having a very hard time catching my breath, and I am so
swollen, I keep gaining weight.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 76 year old female who was referred to Doctor J.P. by her primary care physician for admission from the
emergency room. Patient presented to the emergency room on 2/7/ 14 complaining of shortness of breath. She explains
that it has been going on for several weeks and gets worse week after week. She says that nothing seems to relieve the
feeling and that her surgery being postponed is making her very anxious. The patient had a mitral and tricuspid valve
replacement about 5 years ago. She initially did well, but had recurrent atrial fibrillation. Patient was recently reevaluated, and found to have severe mitral stenosis and moderate pulmonary hypertension. The last cardiac catheterization
which showed these results was done in December 2013 at Largo Medical. This woman was scheduled to have surgery
today 2/7/14 at Largo Medical Center, but surgery was cancelled because of some scheduling/ equipment issues with the
surgeon. She was then referred to a surgeon at BMC by her physician. An EKG, Chest X-ray and labs were drawn in the
ER and she was placed on a 2L nasal canula. This woman also underwent a CT scan of the thorax on 2/7/14, and the
results were: large pleural effusion, and extensive amount of Ascites. Patient was then transferred to the cardiac floor at
BMC. On 2/10/14 a transesophageal Echocardiogram of the patient showed moderate mitral regurgitation and stenosis,
mild to moderate aortic stenosis, tricuspid valve regurgitation, and a left atrial appendage thrombus was noted. Patient is
scheduled for a mitral/ tricuspid valve replacement on 2/14/14 with Doctor J.P.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
Operation or Illness
Hypertension (Managed with diet and exercise)
Appendectomy
2000, 2008
2004
2009
Hysterectomy (No specific date given, patient states it was in her early 30s)
Total knee replacement surgery
DDD pacemaker for sick sinus syndrome
Open heart surgery with mitral valve replacement and tricuspid valve replacement. (Has been on
Coumadin since then, this was stopped in December for catheterization. Patient is now on Lovanox)
Father
72
Mother
79
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable
)
Lung
cancer
Stroke
Environmental
Allergies
Diabetes Type II (no onset date provided)managed with nutrition and exercise + patient states I
sometimes take Metformin 500 mg twice a day, but I dont like how it makes me feel. In the hospital
it is being managed with sliding scale regular insulin).
Arthritis (hands)
Atrial Fibrillation (no onset date provided)
Alcoholism
2
FAMILY
MEDICAL
HISTORY
1998
2001
Brother
Sister
39
Cancer
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
NO
2
Medications
NAME of
Causative Agent
NKA
NKA
Other (food, tape,
latex, dye, etc.)
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)
Heart failure is the inability of the heart to pump blood at the required rate for the perfusion of vital organs and body
tissues, or the ability to do so with an increased diastolic pressure. Cardiac output of blood is based on Heart rate and
stroke volume which encompasses preload, after load and contractility. In heart failure, preload (stretching and filling of
the heart) and after load (systolic pressure) are increased due to various risk factors observed below; and contractility is
decreased causing the ventricles to work harder. In some cases, contractility is increased to a point where the filling of
blood in the heart is vastly reduced, and blood flow is diminished. The RAA (Renin angiotensin aldesterone) system also
contributes by causing vasoconstriction which obstructs the blood flow, increases absorption of sodium and water in the
body and results in hypertension. This is the number one risk factor of heart failure. (Dumitru, 2013). Chronic
Hypertension is a major risk factor of heart failure because it can lead to hypertrophy of the heart and atherosclerosis
which weaken the pumps abilities therefore increasing the hearts workload (Huether &McCance, 2012, p.589). Other
risk factors include Diabetes mellitus which causes damage to the bodys blood vessels, obesity, Coronary artery disease
(CAD) which blocks blood flow (vasoconstriction) due to plaque buildup, myocarditis (Inflammation and infection),
congenital heart disease, arrhythmias, valve defects, excessive water and salt intake which increase blood pressure in the
body, recreational drugs (alcohol, cocaine), and medications with cardiac side effects (Huether & McCance, p.622).
There are a few different ways to diagnose heart failure; one of them is by testing the brain natriuretic peptide
(BNP) levels in the blood. If the levels are above 100pg/ml, it indicates the presence of heart failure. Depending on how
high the levels are, it can be rated from mild to severe. In this particular Patient, the BNP level was 719 pg/ml. Extra heart
sounds such as an S3 gallop can usually be heard in patients with heart failure, but this should not be used as the only
decisive diagnostic method. To determine which side of the heart is affected, observe for the following signs and
symptoms. In left-sided heart failure, pulmonary edema can occur, the patient manifests with orthopnea, cyanosis, fatigue,
tachycardia, and crackles are usually heard during auscultation. In right-sided heart failure, nausea, vomiting, and right
sided abdominal pain occurs due to liver congestion with blood. This leads to ascites and weight gain in the patient.
Constipation is also often seen in heart failure, and indicates decreased perfusion of blood to abdominal area. In elderly
patients the first signs and symptoms of heart failure can be fatigue and confusion. Other possible signs and symptoms of
diagnosis include tachycardia, chest pain and palpitations, distension of neck veins, and cyanosis. As part of the diagnosis,
patient should also be assessed for a complete cardiac history. (Dumitru,2013)
Heart failure can be stabilized by using treatments such as vasodilators (to dilate blood vessels and facilitate blood
flow), diuretics to decrease blood pressure and edema if present, and as a first line treatment to manage hypertension,
anticoagulants, digoxin, ACE inhibitors which decrease blood pressure by preventing vasoconstriction, and beta blockers
which reduce heart rate and the workload of the heart by blocking adrenaline from attaching to beta receptors. Other more
invasive therapies are also available in extreme cases of heart failure such as pacemakers and implantable cardioverterdefibrillators. Depending on how severe the heart failure is, non-pharmalogical therapies such as dietary sodium and fluid
restriction, lifestyle changes, physical activity as appropriate for patient and attention to weight gain are also available.
The mortality rate for heart failure patients after hospitalization is 22% after 1 year, and increases to 42.3 % at 5 years. If
patient is hypotensive, mortality rate are as high as 80%. Factors that could impact treatment and prognosis include
noncompliance with dietary revision/ lifestyle changes, and inadequate intake or discontinuing of prescribed medication
(Dumitru, 2013).
5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name : Aldactone (spironolactone)
Concentration (mg/ml)
Route PO
Home
Hospital
or
BothX
Indication: Management of edema associated with heart failure, cirrhosis. Management of essential hypertension.
Side effects: Hyperkalemia, GI irritation, dizziness, headache, arrhythmias, hair growth in females, SJS
Nursing considerations: check potassium levels, use with ACE inhibitors can increase risk of hyperkelemia. Monitor Intake and output ratios and daily weight.
Evaluate BP before administration. Signs of hyperkelemia are cardiac arrhythmias, fatigue, confusion, weakness, Paresthesia. Patients with diabetes are at
increased risks for these symptoms. Assess patient for skin rash. Labs: Monitor potassium labs, may decrease sodium levels, and monitor BUN, serum
creatinine. Discontinue 3 days prior to a glucose tolerance test because of risk of hyperkelemia. Administer w/ food or milk to avoid GI irritation.
Name: Lovenox
Concentration: 80mg/0.8 ml
Route: SQ
Dosage Amount: 80 mg
Frequency: Q12
Home
Hospital
or
Both
Concentration:
Route: PO
Home
Hospital
or
Both
Concentration
Route: PO
Frequency: Daily
Home
Hospital
or
Both
Indication: For inflammatory diseases like arthritis and as a prophylaxis of transient ischemic attacks and MI.
Side effects: GI bleeding, nausea and vomiting, abdominal pain, tinnitus, anaphylaxis and laryngeal edema.
Nursing considerations: May increase risk of bleeding in patients on anticoagulants. Ginger and garlic may increase anticoagulant effects. Monitor hepatic
functions and check for increase in labs such as serum AST and ALT. Monitor hematocrit levels to assess for GI blood loss. Check platelet levels. Assess for
toxicity: onset of tinnitus, headache, hyperventilation, mental confusion, lethargy, diarrhea and sweating.
Name: Insulin (regular)
Concentration
Route: SQ
Frequency: AC/ HS
Home
Hospital
or
Both
Concentration: 0.25mg/ ml
Route: IV push
Frequency: Q12
Home
Hospital
or
Both
Concentration
Route: PO
Frequency: BID
Home
Hospital
or
Both
Concentration
Route: PO
Frequency: BID
Home
Hospital
or
Both
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
Name
Concentration
Dosage Amount
Route
Frequency
Pharmaceutical class
Home
Hospital
or
Both
Indication
Side effects/Nursing considerations
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Cardiac diet
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular healthy
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: 1Banana, cup of oatmeal and 1mug coffee
(8ounces)
Lunch: Fruits (1 apple, mixed lettuce w/ tomatoes,
cucumbers,1 can tuna, balsamic vinaigrette )
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 reference.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My house mate Marge.
How do you generally cope with stress? Or What do you do when you are upset? By keeping busy and Marge helps me
cope as well
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
No except this anxiety I have been feeling with this doctor who kept cancelling and postponing my surgery, this is why I
am now here, I found another surgeon with Bayfront.
+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? ______________
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? ______________________
Are you currently in a safe relationship? I am a Widow.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group:
In the Ego Integrity stage, older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads
to feelings of wisdom, while failure results in regret, bitterness, and despair (McLeod, 2008).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
The patient has retired, but she is now running her own business, she mentions that she is the main promotional source for
her community, and that they need her. She feels good that she is still contributing and is able to help people. Patient does
not feel regretful of life, she is able to look back and communicate memories she has and she explained that it gives her a
sense of fulfillment to help her community and contribute.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
It did not really have a huge impact on her stage of life, it might have brought her mood down but she is not in a state of
despair, she has a lot of hope.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
I have no idea; I have a long history of illnesses.
What does your illness mean to you?
I dont know, I am sick that is all I know.
+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 with my
husband.__________________________________________________________________
Do you prefer women, men or both genders?
____Men_________________________________________________________
Are you aware of ever having a sexually transmitted
infection? _____No__________________________________________
Have you or a partner ever had an abnormal pap smear?
_________No____________________________________________ Have you or your partner received the Gardasil
(HPV) vaccination? _____________no______________________________
Are you currently sexually active? ___No________________________When sexually active, what measures do you
take to prevent acquiring a sexually transmitted disease or an unintended pregnancy? None with my husband, but I have
had a hysterectomy.
How long have you been with your current partner? Since I was 18, now I am 76, but he passed when I was 68.
Have any medical or surgical conditions changed your ability to have sexual activity?
_____No______________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
Yes
No
For how many years? X years
(age
thru
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much? House mate Marge smokes but
never inside the house. She always goes outside. Smokes a
pack a day.
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Beer
How much? (give specific volume)
thru
76
1 beer a night
If applicable, when did the patient quit?
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age
thru
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Not that I know of. I live in a safe neighborhood
10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen no
SPF:
Bathing routine: Daily
Other:
HEENT
Difficulty seeing (has reading glasses)
Cataracts or Glaucoma
Difficulty hearing
Gastrointestinal
Immunologic
Genitourinary
Anemia
Bleeds easily
Bruises easily ( On Coumadin since
2008)
Cancer
Blood Transfusions
Blood type if known: OOther:
nocturia
dysuria
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:
hematuria
polyuria (Pt on diuretics)
kidney stones
Normal frequency of urination: 7/8
Bladder or kidney infections
x/day
Hematologic/Oncologic
Metabolic/Endocrine
2
x/day
1 x/year
Diabetes
Type: II
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing Shortness of
breath
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/7/2014 at BMC
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF (has a pacemaker)
Murmur
Thrombus Left atrial
Rheumatic Fever
Myocarditis
Menarche
age? 14
Menopause
age?
Date of last Mammogram &Result:
Unknown
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Childhood Diseases
Measles
Mumps
Polio
10
Osteomyelitis
Scarlet Fever
Arthritis (Hands)
Chicken Pox
Other:
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None
Any other questions or comments that your patient would like you to know?
None
11
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
IV
Incision for prior valve replacement
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3 / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without
nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 5 inches & left ear- 5 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: No dentitions present
Comments:
12
Pulmonary/Thorax:
Crackles present in left lower lobe, all other lobes sound clear with no
adventitious sounds.
Respirations are regular and unlabored with 2L nasal canula on.
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: Not assessed.
Heart sounds: S1 S2 present Regular Irregular (S3 sound auscultated)
No murmurs, clicks, or adventitious heart sounds
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
PT:
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: light yellow
Previous 24 hour output: mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 2 / 12 / 14 ) Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:
Biceps:
Brachioradial:
Patellar:
Achilles:
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):
Lab
Hemoglobin (Normal
12.1- 15.1 gm/dL)
L 11.7
L 11.7
L 9.9
Dates
2/7/14
2/11/14
2/12/14
2/7/14
2/11/14
2/12/14
Trend
The hemoglobin levels
have been trending down
for the patient.
Analysis
Hemoglobin is a protein
in red blood cells that
carries oxygen. Low
hemoglobin may be
indicative of anemia,
destruction of RBC,
malnutrition and vitamin
deficiencies. This leads to
less oxygen perfusion in
the patients tissues.
Patient is on 2 L nasal
canula. Patients RBC has
been decreasing which
negatively affects the
hemoglobin levels in the
body.
This determines how
many red blood cells a
patient has. Red blood
cells contain hemoglobin
which carries oxygen,
therefore a low red blood
cell count can decrease
how much oxygen the
body receives. A low
RBC count can be caused
by bleeding,
2/7/14
2/7/14 11:20AM
2/7/14 17:27 PM
2/7/14
2/11/14
2/12/14
2/7/14
2/11/14
erythropoietin deficiency
secondary to kidney
disease, anemia, and
malnutrition. Note that
patient is on an
anticoagulant which
could increase the risk of
bleeding.
BNP (brain natriutetic
peptide) is a protein made
by the heart. Levels are
higher than normal in
cases of heart failure
because it is secreted in
response to excessive
stretching of the heart
muscle.
Troponin is a protein that
is released when the heart
has been damaged (MI).
If a patient has had a
heart attack, troponin
levels will be above
normal within 6 hours. In
this case the patient has
not sustained any damage
to the heart tissue because
levels are normal.
Potassium is an
electrolyte in the body.
Potassium (K+) helps
nerves and muscles
communicate. It also
helps move nutrients into
cells and waste products
out of cells. This patient
is on a potassium sparring
diuretic and on a
potassium supplement,
and potassium levels are
consistently increasing, so
the nurse must monitor
labs to avoid
hyperkelemia.
Hyperkelemia can result
in cardiac dysrhythmias
and arrest.
Sodium is an electrolyte
that the body needs to
work properly. Low
L131
L134
137
2/12/14
2/7/14
2/11/14
2/12/14
2/7/14
2/11/14
2/12/14
2/7/14
2/11/14
TEE (Transesophageal
Echocardiogram)
2/10/14
Interpretation: moderate
mitral stenosis and
regurgitation was noted,
mild to moderate aortic
valve stenosis was
shown, moderate
tricuspid regurgitation,
and a left atrial
appendage thrombus
were displayed.
pacemaker.
4. Fluid volume excess r/t decreased cardiac output and water retention AEB s3 heart sounds, weight gain and respiratory
distress
5. Ineffective tissue perfusion r/t to decreased cardiac output AEB edema and altered BP readings.
6. Risk for impaired skin integrity r/t edema, decreased physical mobility and decreased tissue perfusion.
7. Fatigue r/t to heart failure AEB generalized weakness.
8. Deficient knowledge regarding condition, treatment regimen, self care and discharge needs r/t lack of understanding of
cardiac disease AEB statements of concern and misconception.
15 CARE PLAN
Nursing Diagnosis: (Impaired gas exchange r/t to fluid collection AEB shortness of breath and peripheral edema.) (Ackley & Ladwig, 2011)
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
1) Patient will maintain adequate
1) Auscultate breath sounds Q4
1) Reveals presence of pulmonary
Patient had an SPO2 of 94 % and
gas exchange and oxygen
noting any crackles or wheezes.
congestion indicating need for
they were maintained on 2L nasal
saturation above 92% throughout
2) Weight patient daily.
further interventions.
canula. Patient was in no distress
shift.
3) Instruct/teach patient effective
2) Drastic weight gain in a few
and did not have shortness of
coughing and deep breathing
days can indicate how much fluid
breath unless she was disconnected
(Ackley & Ladwig, 2011).
retention is occurring.
from the oxygen and walked to the
3) clears airway and facilitates
bathroom. Short term goal was
4)
Encourage
frequent
position
oxygen
delivery
successful, and long term goal is
2) Patient will demonstrate
change for patient.
still in progress.
adequate ventilation and
5)
Monitor
pulse
oximetry
Q4,
and
4)
This
helps
prevent
Atelectasis
oxygenation of tissues by
serial ABGS with changes in
and pneumonia.
ABGs/oximetry within patients
status.
5) Hypoxemia can be severe during
normal ranges and free of
6) Administer supplemental oxygen pulmonary edema; any changes
symptoms of respiratory
as indicated.
should be noted.
distress
7) Maintain head of the bed
6) May correct or reduce tissue
elevated at 20-30 degrees/ semi
hypoxemia.
fowler position. Support arms with 7) Reduces oxygen consumption
pillows.
and demands and promotes
8) Administer medications
maximal lung inflation while
(diuretics, bronchodilators) as
patient is breathing.
indicated
8) Enhances gas exchange by
increasing oxygen delivery, reduces
pulmonary congestion.
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 patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output related to valvular stenosis and altered heart rate AEB presence of s3 sound, edema and a pacemaker. (Ackley &
Ladwig, 2011)
Patient Goals/Outcomes
1) Patient will report
decreased/absent episodes of
dyspnea on this shift.
Evaluation of Interventions on
Day care is Provided
After these interventions, patients
heart workload has been decreased,
they have been experiencing less
episodes of shortness of breath, and
vital signs are being monitored
every 4 hours.
References
Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.