--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
Physical exam
Currently sleeping on 3 pillows at night to ease breathing.
6--20--02
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
2
SAT level -- 90% on room air. Denies chest pain.
Medications ordered
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
Observations
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.
--2-- NSGCARE PLAN(Sample):2:1/06SAMPLE NURSING CARE PLANRIVERSIDE COMMUNITY COLLEGE DATENURSING EDUCATIONSTUDENT________________________________ SEMESTERINSTRUCTOR____________________________ ROTATION
Client’s Initials J.R. Gender M Age 84 Code Status Full Admission Date 6--20--02Presenting Signs/Symptoms (What brought the client to the hospital?)Increasing fatigue and SOB x 3--4 weeksAdmitting/Primary DiagnosisChronic CHF with acute exacerbationSurgeries Related to this AdmissionNoneSecondary Diagnoses (Diagnoses other than admitting diagnosis that impact this admission.)CAD (coronary artery disease). S/P MI (1988)History of Present Illness (What led up to this hospitalization?)Client became more SOB and tired 3--4 weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented toE.R. with
↑
SOB and dyspnea.Previous Surgical Procedure(s) / Date(s)Balloon Angioplasty (1 vessel) 2000Health History (Include length of time client has had disease processes; significant family history; social issues.)CAD x 10 years. CHF x 5 years. MI 1988.Substance Use (Include use of tobacco, alcohol, street drugs, over--the--counter drugs, length of use and time of last use.)2 PPD x 40 years. Quit 1990. Denies ETOH, drug use.Allergies/Reactions NKAReligious Preference Catholic Ethnicity Hispanic Marital Status W Occupation Retired
Pathophysiology/Current Health Problems and Related Functional Changes: Define each primary andsecondary diagnosis and explain the disease process of each. Also include signs and symptoms, risk factors, treatment options, possible complications, and functional changes that affect activities of dailyliving (ADLs). Source: Smeltzer and Bare, 2000CHF: Congestiveheartfailure(CHF)oftenreferredtoascardiacfailure,istheinabilityofthehearttopumpsufficientbloodtomeettheneedsofthetissuesforoxygenandnutrients. Aswithcoronaryarterydisease,incidence increases with age. Common underlying conditions that lead to decreased myocardialcontractility include myocardial dysfunction (especially from coronary atherosclerosis), arterialhypertension and valvular dysfunction (p. 622). Functional changes relate to inadequate tissue perfusion,dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities, oliguria, sodium and fluidretention. Increased pulmonary venous pressure leads to cough, SOB and pulmonary edema. Increasedsystemic venous pressure may result in generalized edema and weight gain (p. 665).CAD: ThemostcommonheartdiseaseintheU.S.isatherosclerosis,whichisanabnormalaccumulationof lipid,orfattysubstancesandfibroustissueinthevesselwall. Thesesubstancescreateblockagesornarrowthevesselinawaythatreducesbloodflowtothemyocardium(p.594). Functionalchangesdependonthedegree of narrowing. Angina pectoris is recurrent chest pain that is brought on by physical exertion oremotional stress and relieved by rest or medication (p. 595).
--3-- NSGCAREPLAN(Sample):3:1/06Therapeutic/Multidisciplinary Treatment Plan: (Textbook) Source Smeltzer and Bare, 2000CHF: Medical: Reduce workload of heart; increase the force and efficiency of myocardialcontractionandeliminatetheexcessiveaccumulationofbodywaterbyavoidingexcessfluidintake;controlling the diet and monitoring diuretic and angiotensin--converting enzyme (ACE) inhibitortherapy (p. 665). Nursing: Administer medications and assess the medication effects. Assesspatient’s: intake and output; weight; lung sounds; vital signs; skin turgor and mucous membranes.Assess patient for JVD, edema and signs/symptoms of fluid overload (p. 668). Nurses performcounseling and education concerning regular exercise, sodium restriction, and avoidance of excessive fluid intake, alcohol and smoking (p. 668). Pharmacist: Review of medications used fortreatmentofCHFincludingACEinhibitors,diuretictherapy,digitalis. Monitoringbloodlevelssuchas digoxin (in collaboration with MD and nursing) (p. 666). Registered dietitian: Nutritionassessment and counseling regarding sodium restriction, avoidance of excessive fluid intake andalcohol (p. 668). Respiratory therapist: Administer oxygen therapy based on the degree of pulmonarycongestionandresultinghypoxia. Somepatientsmayneedsupplementaloxygentherapyduring activity. Others may require hospitalization and endotracheal intubation (p. 666).CAD: Prevention of CAD by controlling these risk factors is important: high cholesterol, cigarettesmoking, hypertension and diabetes mellitus (p. 595). If CAD is associated with angina, medicalmanagement with drugs and control of risk factors is implemented to decrease the oxygen demandsofthemyocardiumandtoincreasetheoxygensupply(p.598). Revascularizationproceduresincludecoronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty(PTCA, also known as balloon angioplasty) (p. 598). Medications include: Ntg, Beta blockers,calcium channel blockers, antiplatelet and anticoagulants (pp. 598--599).
Prescribed Treatments (as per physician’s orders)
Oxygen: 3 LPM via N/CRespiratory Treatment: N/AIV Infusion: Heparin lock Diet: NASFeeding: Requires assistanceBowel/Bladder: BRP with assistanceHygiene: AssistActivity: As tolerated with assistOther: I & O; daily wts.Requires W/C for transportElevate HOB
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