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ASSOCIATE NURSING PROGRAM Student Name: ___Blanca Suarez________ Date: 10/23/2012 Instructor: ___Adria Diaz________ Clinical Site: ____Palmetto Hospital_______
Patient Information DOB: 10/01/1947 Age: 65 Ethnic Group: White / AA / Hispanic / Asian Allergy: PCN HGT: 57 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.
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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.
Family history:
Mother 79, deceased of CAD. Father 54, deceased, heart attack. No brothers or sisters. There is a positive family history of hypertension, but 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: BP: 176/96 HR: 103 Rhythm- Iregular S1-s2 mild heart murmur HR: 89 Coagulation
PT 11 secs PTT 65 secs
RR: 22
Temp: 98.6 Taken Oral route Temp: 98.5 Other: (U/A, ABGs, Protombin, etc)
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%
Current Vital Sign: BP: 160/80 Laboratory Studies: CBC Metabolic Panel
WBC 5,000-10,000/mm3 RBCs 4.2-6.1 x 106/g Hgb 11.5-17.5 g/dl Hct 40-52%
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
LDL 160-189 mg/dL HDL 60 mg/dL Cholesterol total 260 mg/dl Triglycerides 180 mg/dl
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Medication List
Medication/Order Dose
Digoxin
Indication
Increase cardiac output
Usual Dose
QD 0.25 mg
Side effects
Headache, dysrhythmias, hypotension, AV block, blurred vision, yellow--green halos, Circulatory collapse, loss of hearing, hypokalemia, Hypochloremic alkalosis hyperglycemia, nausea, polyuria, renal failure, thrombocytopenia, anemia, rash pruritis, Postural hypotension, collapse, HA, flushing, dizziness N/V, anorexia, diarrhea, cramps
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.
Lasix
PO BID 40 mg
Prevent chest pain; increase cardiac output Dilates Coronary arteries; decreases preload and afterload Prevent Constipation. Bulkforming laxative
15 ml P. O. qHs
Replace Potassium Needed for 20 mEq Transmission of nerve P. O. BID impulses and cardiac contraction
Cardiac depression, dysrhythmias, arrest, peak T waves, low R & RST, prolonged PR interval, wide QRS
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. 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 Diagnoses
(.related to...secondary to .evidenced by..)
Desired Outcome
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 patients: intake and output; 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 (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. 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 decreases work of breathing, reduces cardiac workload, and prompts gas exchange. These are signs of increasing respiratory distress that require prompt intervention. 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.
ND2) Fluid volume excess as evidenced by edema. Dyspnea on exertion (DOE): c/o shortness of breath with mild exertion.
Explain measures that can be taken to treat or prevent excess fluid volume by discharge. Demonstrate adequate tissue perfusion until discharge. Short term goal: Lungs clear to auscultation by time of Discharge
ND3) Decreased cardiac output. Ineffective tissue Perfusion, as evidenced by edema in extremities.
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
Keep the client warm and have the client wear socks and shoes when
Page 6 of 7 changes in lifestyle needed to increase tissue perfusion. Long term goal: Client will have Adequate cardiac output Client will be able to perform/resume ADL without increased exertion.
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 bodys 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 Patients Objective Finding:____________________ (25%) Care Plan Development: ___________________ (50%) Comments: