Patient Initials: A,Z, Rm#346 Age:63 ,F, Allergies:Penicillin, Sulfa, Ceftriaxone.

Date of care: 9/8/2107

Primary Dx: Infectious Endocarditis

Co-morbidities and PMH: Lung Cancer, atrial fibrillation, atrial flutter, hypertension, and anxiety.

How do these impact primary dxs? Patients oxygenation status is already compromised due to endocarditis; history of lung cancer worsens the situation as some of the lung tissue
has been removed and lungs do not function to their full capacity, so it will compromise oxygenation of the tissues even more. The fact that this patient has atrial fibrillation puts
her in danger of emboli that can originate in the heart and lodge in lungs producing respiratory failure and very often resulting in death. Hypertension puts even more strain on
already weakened heart and anxiety affects general well being of the patient as it can produce fight or flight response and put a burden on the heart once more.
Pathophysiology: The hallmark of endocarditis is damage to endothelial lining on heart valves. Endocarditis starts as endothelial lining gets damaged and microthrombi form on
malformed or stenotic valves. At that point if a person develops any bacterial or fungal infection in the blood, even very light one, microthrombi get colonized and infected (Lewis,
Dirksen, Heitkemper, Bucher, & Harding,p. 811,2015). Inflammatory response ensures, thrombi get larger, collagen gets destroyed and cusp perforates. Patients with congenital
heart disease, valve disease, and valve prosthesis are at increased risk of endocarditis and should be treated prophylactically with antibiotics for any invasive
procedures. Endocarditis is most often caused by gram-positive cocci as well as Haemophilus parainfluenzae, Actinobacillus, Actinomycetemcomitans, Cardiobacterium hominis,
Eikenella corrodens, Kingella kingae. Left sided valves get infected most commonly; infection of tricuspid and pulmonary valves is usually suggestive of IV drug abuse (Pathology of
Infectious Endocarditis).

Actual/Potential Complications: Potential for dyspnea, potential for decreased tissue perfusion, actual infection.

Student Name:
Patient Initials:___A.Z__, Rm#346__ Age:,F, Allergies: Penicillin, Sulfa,Ceftrixazone_ Date of care:__9/8/2017 _________
OXYGENATION (Cardiac and Respiratory) Priority# 1 MOBILITY Priority#5
Assessment: O2 sat 99% on room air, left lungs are clear, no SOB.BP 92/48, Assessment: Patient ambulates on her own, has strong upper and lower extremities, full ROM,
pulse is 80, no JVD, patient is in atrial fibrillation, chest expand evenly and Patient is at moderate risk for falls (Morse score of 35).
symmetrically, capillary refill less than 3 seconds on all extremities, no edema, all
pulses are present and +2. Meds:Sotalol, Metoprolol prn, oxycodone prn

Meds: sotalol 80 mg po every 12 hours, apixaban 5 mg po every 12 hours, digoxin Labs:

0.125 mg po daily, Metoprolol 5 mg IV push bid prn.
Ordered Medical Treatments:
Labs: Hct 32.5%, RBCs 3.74, Hgb 11, temp. 98.8, resp. 18, pulse 86,80, BP
92/48,110/68, O2 sat on RA 99%, EF 65%, TEE shows vegetation on mitral valve. NANDA/Nursing Diagnosis: Risk for falls r/t dizziness as evidenced by patient c/o dizziness after
Ordered Medical Treatments: taking BP meds, patient is unsteady on her feet at times, patient has to hold on the furniture
when feeling dizzy.
NANDA/Nursing Diagnosis: Risk for Decreased Cardiac Output r/t disorders of the
heart valves and the endothelium as evidenced by patient has diagnosis of NOC: Safety Behavior: Fall Prevention
endocarditis, patient is on sotalol and digoxin, patient states that her BP falls
down low sometimes. Expected Outcomes:
v Long-term goal: Patient will remain free of falls by week one.
NOC: Cardiac Pump Effectiveness v Short-term goal: Patient will call for assistance when she feels unstable and dizzy this
shift.
Expected Outcomes:
v Long-term goal: Patient will demonstrate adequate cardiac output as NIC: Safety
evidenced by BP, HR, and rhythm within normal parameters for patient by
week one. 1.Monitor: Assess patient for orthostatic hypotension this shift as ordered (Ackley,
v Short-term goal: Patient will remain free of side effects from a medication Ladwig, Makic, p.356).
that is used to improve cardiac output this shift.
2. Teach: Teach patient to call for help to ambulate to the bathroom when she feels dizzy
NIC: Circulatory Care and unstable every shift (Ackley, Ladwig, Makic, p.356).

1.Monitor: Assess patients BP and HR every 4 hours ATC every shift 3. Direct Care: Provide bedside commode for this patient to minimize possibility of fall due
(Ackley, Ladwig, Makic, p.188). to weakness every shift (Ackley, Ladwig, Makic, p.357).

2. Teach: Teach patient to get up from the bed slowly to prevent 4. Direct Care: Place a bed alarm on patients bed this shift (Ackley, Ladwig, Makic,
orthostatic hypotension (Ackley, Ladwig, Makic, p.189). p.358).

3. Direct Care: Administer Sotalol 80 mg every 12 hours as ordered this 5. Direct Care: Provide patient with non-slip socks to promote safety during ambulation
shift (Ackley, Ladwig, Makic, p.189). every shift (Ackley, Ladwig, Makic, p.358).

4. Direct Care: Assist patient to the bathroom if a patient feels dizzy and
weak every shift (Ackley, Ladwig, Makic, p.189).
Actual Outcomes:
5. Teach: Teach patient to report any dizziness, palpitations, and chest pain 1.Patients Vitals taken, standing BP is 20mmHg lower than sitting BP.
to the nurse immediately every shift (Ackley, Ladwig, Makic, p.187). 2.Patent is instructed to call for help when ambulating, but she still insists to ambulate
independently.
3.Bedside commode is provided for the patient.
4.Attempted to put a bed alarm on patients bed, but patient declined.
Actual Outcomes: 5. Non-slip socks provided and accepted by the patient.
1. After Sotalol administered at 9pm, patients BP is 74/45 at 0200, HR is 86.
Patient is alert and responsive, reports weakness and dizziness. Evaluation:
2. Patient is instructed to get up from bed slowly and to change positions slowly to 1. I will continue to monitor patient for orthostatic hypotension as ordered every shift
minimize orthostatic hypotension. for 3 days.
3. Sotalol given at 2100 as ordered, BP 112/76 at the time of administration, HR 2. I will continue to educate patient about the importance of calling for assistance when
86. ambulating every shift.
4. Patient refused any assistance, even though she stated she felt dizzy. 3. I will empty bedside commode and ensure that it is in easy access for patient every
5. Patient verbalized understanding of reporting dizziness, palpitations, and chest shift.
pain to the nurse as soon as it occurs. 4. I will move patient closer to the nursing station in order to have increased
observation by team members as the patient is refusing the use of bed alarm.
Evaluation: 5. I will make sure that patient is wearing non-slip socks every shift.
1.I will contact primary MD right away and report her patients BP after Sotalol
administration. I will request possible dose adjustment and fluids to raise BP up
this shift.
2. I will continue to monitor patient and will continue to instruct her to change
positions slowly every shift.
3. MD contacted, new order received to hold next dose of Sotalol and to
reevaluate patients BP. Bolus of 500 cc of NS ordered.
4. I will continue to educate the patient on importance of asking for help to
ambulate when feeling dizzy every shift.
5. I will continue to teach patient about importance of reporting dizziness, chest
pain, and weakness as it occurs every shift.

Student Name:
Patient Initials: A,Z, Rm#346 Age:63 ,F, Allergies:Penicillin, Sulfa, Ceftriaxone. Date of care: 9/8/2107
NUTRITION Priority#__6___
Elimination Priority#__8_____ Assessment: Patient on Heart Healthy diet, weight 158lb, BMI is 26.3, patient swallows well,
Assessment: Patient is continent, ambulates to the bathroom, bowel sounds are uvula rises in midline, eats 70-80 % of his meals, no risk for aspiration
active in all 4 quadrants, abdomen is soft, last bowel movement today, urine is Meds: Pepcid
yellow and clear, voided 3 times. Labs: Potassium 3.4, albumin 3.1, creatinine 0.4
Ordered Medical Treatments:
Meds:
NANDA/Nursing Diagnosis: Readiness for Enhanced Nutrition r/t patients efforts to get better
Labs: as evidenced by patient asked about Heart Healthy diet, patient orders from the menu
Ordered Medical Treatments: appropriate choices, patient wants information about heart healthy snacks.

NANDA/Nursing Diagnosis: Risk for Constipation r/t decreased mobility and opioid NOC: Nutritional Status
use as evidenced by patient states she does not have BM every day, patient states
her stools are hard to pass sometimes. Expected Outcomes:
v Long-term goal: Patient will verbalize understanding regarding DASH and Healthy Heart diet
guidelines by week two.
v Short-term goal: Patient will order healthy choices from the menu this shift.

NIC: Nutritional Counseling

1.Monitor: Assess the clients usual intake of fiber every shift (Ackley, Ladwig, Makic,
p.611).

2. Teach: Teach the patient how to read nutritional labels every shift (Ackley, Ladwig,
Makic, p.612).

3. Teach: Explain to the patient how to select food from Heart Healthy menu every shift
(Ackley, Ladwig, Makic, p.611).

4. Teach: Recommend to the client to eat fish like salmon or tuna at least twice per week
to ensure adequate intake of omega-3 fatty acids every shift (Ackley, Ladwig, Makic, p.612).

5. Direct Care: Provide client with healthy snacks such as nuts every shift (Ackley, Ladwig,
Makic, p.612).

Actual Outcomes:
1. Client consumes about 10 grams of fiber daily.
2. Patient verbalizes understanding on reading nutritional labels this shift.
3. Patient verbalizes understanding on how to select foods from a Heart Healthy menu and orders
appropriate foods.
4. Patient states that she does not like fish, and wants to know more about omega-3
supplements.
5. Nuts given to the patient in substitution of usual potato chips.

Evaluation:

1. I will encourage patient to consume 25 grams of fiber daily.

2. I will continue to teach patient how to read nutritional labels every shift.
3. I will monitor patients selection from the menu and will be available to provide
guidance and answer questions every shift.
4. I will arrange a meeting with a dietitian for a patient per patients request this shift.
5. I will continue to provide healthy snacks for a patient every shift.

Student Name:
Patient Initials:___A.Z__, Rm#346__ Age:,F, Allergies: Penicillin, Sulfa,Ceftrixazone_ Date of care:__9/8/2017 _________
FLUID BALANCE Priority#___3____ Skin and Tissue Integrity Priority#__4_____
Assessment: Intake 1220 ml of oral fluids, intake of 100 cc of IV fluids, voided 3 Assessment: Skin is pink, smooth, non-tenting, good skin turgor, skin is intact, right midline, no
times, no edema, no JVD, non-tenting skin with good turgor opened areas, Braden scale is 19, not at risk for pressure ulcers.
Meds: IV Meropenem
Meds:
Labs: Hgb 11, Hct 32.5%, potassium 3.4, creatinine 0.4, albumin 3.1
Medical treatments:
Ordered Medical Treatments: n/a
NANDA/Nursing Diagnosis: Risk for Impaired Skin Integrity r/t inadequate protein intake as
NANDA/Nursing Diagnosis: Risk for Electrolyte Imbalance r/t compromised evidenced by albumin is 3.1, patient states she does not like to eat too much protein.
regulatory mechanism as evidenced by patients K is 3.4, patient has daily blood
draws.

NOC: Electrolyte balance

Expected Outcomes:

v Long-term goal: The client will be in sinus heart rhythm with a regular rate
by discharge
v Short-term goal: The client will have normal serum potassium level this shift

NIC: Electrolyte Monitoring

1.Monitor: Monitor vital signs every 4 hours this shift (Ackley, Ladwig,
Makic, p.349).

2. Monitor: Monitor cardiac rate and rhythm on continuous telemetry every

day (Ackley, Ladwig, Makic, p.349).

3. Monitor: Monitor patients labs every day and report changes to provider
(Ackley, Ladwig, Makic, p.397).

4. Direct Care: Administer IV fluids as ordered and monitor their effects

every shift (Ackley, Ladwig, Makic, p.350).

5. Teach: Teach patient about s/s of hypokalemia and the risk factors every
shift (Ackley, Ladwig, Makic, p.350).

Actual Outcomes:
1.Patients BP is 78/42, HR 80 after sotalol administration.
2. Heart rate is 80-96, patient remains in a-fib this shift.
3. Patients potassium level is 3.4, which is slightly below the normal level.
4. Bolus of normal saline given to the patient to remedy hypotension, BP is 98/52
after the bolus.
5. Patient verbalizes understanding that s/s of hypokalemia include muscle
weakness, irregular pulse, vomiting and constipation.

Evaluation:
1. I will continue to monitor patients BP every 4 hours around the clock.
2. I will continue monitor patients heart rate and rhythm on telemetry
continuously.
3. I will continue to monitor patients daily labs and report high and low
values to provider.
4. I will monitor new orders for any STAT orders and will implement them
every shift.
5. I will continue to educate patient about s/s of hypokalemia every
shift.

Neurosensory Priority#_7___ Wellness Priority#_9___

Assessment: Alert and oriented times 4,vision and hearing good Assessment: she does not have family in the area. She feels confined and lonely in the hospital.
Meds: Labs:
Labs: Ordered Medical Treatments:
Ordered medical treatments: Meds:
NANDA/Nursing Diagnosis: Risk for Stress Overload r/t disease process and NANDA/Nursing Diagnosis: Risk for Loneliness r/t hospitalization as evidenced by patient sits in
hospitalization as evidenced by patient states she feels out of control being in the her chair with her head down, patient states she was in and out of the hospital for months and
hospital for so long, patient expresses stress and concern about her condition. feels alone.

Student Name:
Patient Initials: A,Z, Rm#346 Age:63 ,F, Allergies:Penicillin, Sulfa, Ceftriaxone. Date of care: 9/8/2107
Self Expression Priority#_10___
Assessment: Patient is single, does not have family in the area, c/o anxiety at
times, does not attend church, and has several close friends in the area.
Meds:
Ordered Medical Treatments:
NANDA/Nursing Diagnosis: Risk for Situational Low Self-Esteem r/t isolation and
chronic health problems as evidenced by patient states she will never be able to
function normally again, she expresses she is burden to her friends with her
complaints and health problems.
Sleep/Pain/Rest Priority#_2_____
Assessment: Patient is on Melatonin for sleep, she states she has hard time falling asleep
sometimes, Pain level is 0 right now.
Labs:
Meds: melatonin HS, oxycodone prn for pain
NANDA/Nursing Diagnosis: Insomnia r/t stressor as evidenced by patient is on Melatonin, Patient
takes Xanax for anxiety, patient states she has hard time falling asleep sometimes.

NOC: Sleep

Expected Outcomes:

Long-term goal: Patient will wake up less during the night, a minimum of
four nights out of seven in two weeks.
Short-term goal: Patient will sleep of minimum 6 hours tonight.
NIC: Sleep Enhancement

1. Monitor: Explore bedtime routines every shift (Ackley, Ladwig, Makic, p.545).
2. Teach: Teach patient to engage in relaxing activity before nighttime in order to wind
down(Ackley, Ladwig, Makic, p.546).
3. Direct Care: Provide patient with warm herbal tea at HS to promote relaxation every
shift (Ackley, Ladwig, Makic, p.546).
4. Direct care: Administer melatonin at HS as ordered every night (Ackley, Ladwig,
Makic, p.545).
5. Direct Care: Cluster care to avoid unnecessary interruptions during the night daily
(Ackley, Ladwig, Makic, p.546).

Actual outcomes:
1.Patient watches a lot of TV before bed, which may interfere with her sleep.2.
2. Patient is trying to color instead of watching TV before bedtime tonight.
3.Patient was given warm chamomile tea before bed tonight.
4.Melatonin administered as ordered at HS.
5. Vital signs, medpass and bedbath clustered together to avoid waking up patient
later tonight.

Evaluation:
1. I will continue to monitor patients bedtime routines daily.
2. I will continue to encourage patient to engage in calm activities before sleep.
3. I will continue to provide patient with warm drinks and offer warm bedbath
before HS to promote sleep.
4. I will continue to administer melatonin as ordered every HS.
5. I will monitor the effectiveness of the interventions and will get a consult for
sleep specialist if patient is still having hard time sleeping.

References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. (n.d.). Nursing diagnosis

handbook: An evidence-based guide to planning care.

Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M.
(2015). Medical-surgical nursing: assessment and management of clinical
problems. St. Louis, MO: Elsevier/Mosby.

Pathology of Infectious Endocarditis. (2017, January 06). Retrieved

September 10, 2017, from
http://emedicine.medscape.com/article/1954887-overview#a1

Student Name: