--1-- NSGCAREPLAN(Sample):1:1/06NURSING CARE PLAN SAMPLE DATABASEMr. Jose Rodriguez, an 84--year--old client, was admitted to the hospital on 6/20/02 with shortness of breath. This retired Hispanic grower, a widower, states that for the past 3--4 weeks he has had increasingfatigueandshortnessofbreath. Hevisitedhisdoctortwodaysago,andhismedicationwasincreased. Hispreferredfoodsarefreshfruitsandvegetables,rice,redbeansandtortillas. Mr. Rodriguezliveswithoneof hisdaughtersandherfamilysinceexperiencingamyocardialinfarctionin1988. Hehassixotherchildren.HeisaCatholicandattendschurchregularly;however,sincehisdeclininghealth,hehasbeenconfinedtohis home. He is visited at home weekly by his church pastor and/or representative. He speaks with prideabout his grocery store that he started for his family. He smoked two packs per day x 40 years and quit in1990.Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure (CHF) with acuteexacerbation. His medical history includes coronary artery disease x 10 years. He had a balloonangioplastyin2000andanM.I.in1988. Heishearingimpairedandwearsbilateralhearingaids. Hewearsglassesandreadswithoutdifficulty. ThisishisthirdadmissionforCHFsincehisdiagnosisfiveyearsago.Physician progress notes from 6/22/02 state: Condition improving; c/o decreasing SOB; chest x--rayimproving; serum K+ is 3.3, and weight decreased 8# in past two months.
Admitting history and
Moderate respiratory distress; crackles auscultated in left lung base
Currently sleeping on 3 pillows at night to ease breathing.
Nocturia X4 this past week.Mild heart murmur; no JVD, peripheral pulses +2;VS: 98.6--88--28, 176/94, Ht. 5’7”, Wt. 154#, Baseline BP 145/90c/o increasing fatigue and severe shortness of breath (SOB)O
SAT level -- 90% on room air. Denies chest pain.
6--20--02 Digoxin 0.25 mg po QD6--20--02 Lasix 40 mg po bid6--20--02 Nitro--Bid 2.5 mg po qid6--20--02 Metamucil 15 ml po q hs in glass of water/juice6--20--02 KCl 20 mEq po bid
Diagnostic tests results
6/22/02 Chest x--ray--mild left ventricular hypertrophy; pulmonarycongestion resolving.6/20/02 Serum electrolytes:Na+ 138 mEq/LK+ 3.3 mEq/LCa+ 9.1 mg/dlCL-- 102 mEq/L6/20/02 Serum albumin 2.8 g/dl6/20/02 Serum digoxin level 2.6 ng/dl6/20/02 Bun 30 mg/dlCr 0.6 mg/dl
Other admitting orders
No added salt diet; I & O, daily wts, activity as toleratedBRP with assist, VS Q 4 hoursO2 at 3L/min per nasal cannulaHeparin lock
Nursing Interview &
States “my old heart is just wearing out. I get this extra fluid every now
and then. I come here to the hospital to get rid of it.” Seems well orientedandisafluenthistorian;accuratelyreportedmedshehadbeenonathome.c/o constipation. Skin reddened over bony prominences. Currentlyrequires HOB elevated to ease breathing. Requires W/C for transport.Needs ADL assist. Gait unsteady. Family at bedside.