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10060310 Nursing Care Plan Sample Cardiac

10060310 Nursing Care Plan Sample Cardiac

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Published by jlfreeman6

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Published by: jlfreeman6 on Nov 29, 2009
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NURSING CARE PLAN SAMPLE DATABASE Mr. Jose Rodriguez, an 84-year-old client, wasadmitted to the hospital on 6/20/02 with shortness of breath. This retiredHispanic grower, a widower, states that for the past 3- weeks he has hadincreasing -4 fatigue and shortness of breath. He visited his doctor two days ago,and his medication was increased. His preferred foods are fresh fruits andvegetables, rice, red beans and tortillas. Mr. Rodriguez lives with one of hisdaughters and her family since experiencing a myocardial infarction in 1988. Hehas six other children. He is a Catholic and attends church regularly; however,since his declining health, he has been confined to his home. He is visited athome weekly by his church pastor and/or representative. He speaks with pride abouthis grocery store that he started for his family. He smoked two packs per day x 40years and quit in 1990. Mr. Rodriguez was admitted with a diagnosis of chroniccongestive heart failure (CHF) with acute exacerbation. His medical historyincludes coronary artery disease x 10 years. He had a balloon angioplasty in 2000and an M.I. in 1988. He is hearing impaired and wears bilateral hearing aids. Hewears glasses and reads without difficulty. This is his third admission for CHFsince his diagnosis five years ago. Physician progress notes from 6/22/02 state:Condition improving; c/o decreasing SOB; chest x-ray improving; serum K+ is 3.3,and weight decreased 8# in past two months. Admitting history and Physical exam 6--02 -20Moderate respiratory distress; crackles auscultated in left lung baseCurrently sleeping on 3 pillows at night to ease breathing. Nocturia X4 this pastweek. Mild heart murmur; no JVD, peripheral pulses +2; VS: 98.6- -28, 176/94, Ht.5’7”, Wt. 154#, Baseline BP 145/90 -88c/o increasing fatigue and severe shortnessof breath (SOB) O2 SAT level - 90% on room air. Denies chest pain. 6- -02 -206--02 -206- -02 -206- -02 -206- -02 -206/22/02 6/20/02 Digoxin 0.25 mg po QD Lasix40 mg po bid Nitro-Bid 2.5 mg po qid Metamucil 15 ml po q hs in glass ofwater/juice KCl 20 mEq po bid Chest x-ray-mild left ventricular hypertrophy;pulmonary congestion resolving. Serum electrolytes: Na+ 138 mEq/L K+ 3.3 mEq/L Ca+9.1 mg/dl CL- 102 mEq/L Serum albumin 2.8 g/dl Serum digoxin level 2.6 ng/dl Bun30 mg/dl Cr 0.6 mg/dlMedications orderedDiagnostic tests results6/20/02 6/20/02 6/20/02 Other admitting ordersNo added salt diet; I & O, daily wts, activity as tolerated BRP with assist, VS Q4 hours O2 at 3L/min per nasal cannula Heparin lock States “my old heart is justwearing out. I get this extra fluid every now and then. I come here to thehospital to get rid of it.” Seems well oriented and is a fluent historian;accurately reported meds he had been on at home. c/o constipation. Skin reddenedover bony prominences. Currently requires HOB elevated to ease breathing. RequiresW/C for transport. Needs ADL assist. Gait unsteady. Family at bedside.--1NSGCAREPLAN(Sample):1:1/06Nursing Interview & Observations
SAMPLE NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATIONSTUDENT________________________________ SEMESTERINSTRUCTOR____________________________ ROTATIONClient’s Initials J.R. Gender M Age 84 Code Status Full Admission Date 6- -02 -20-Presenting Signs/Symptoms (What brought the client to the hospital?) Increasingfatigue and SOB x 3- weeks -4 Admitting/Primary Diagnosis Chronic CHF with acuteexacerbation Surgeries Related to this Admission NoneSecondary Diagnoses (Diagnoses other than admitting diagnosis that impact thisadmission.) CAD (coronary artery disease). S/P MI (1988) History of PresentIllness (What led up to this hospitalization?) Client became more SOB and tired 3-weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented to -4 E.R. withSOB and dyspnea. Previous Surgical Procedure(s) / Date(s) Balloon Angioplasty (1
 vessel) 2000 Health History (Include length of time client has had diseaseprocesses; significant family history; social issues.) CAD x 10 years. CHF x 5years. MI 1988. Substance Use (Include use of tobacco, alcohol, street drugs,over- -counter drugs, length of use and time of last use.) -the2 PPD x 40 years.Quit 1990. Denies ETOH, drug use. Allergies/Reactions Religious Preference NKACatholic Ethnicity Hispanic Marital Status W Occupation RetiredPathophysiology/Current Health Problems and Related Functional Changes: Defineeach primary and secondary diagnosis and explain the disease process of each. Alsoinclude signs and symptoms, risk factors, treatment options, possiblecomplications, and functional changes that affect activities of daily living(ADLs). Source: Smeltzer and Bare, 2000 CHF: Congestive heart failure (CHF) oftenreferred to as cardiac failure, is the inability of the heart to pump sufficientblood to meet the needs of the tissues for oxygen and nutrients. As with coronaryartery disease, incidence increases with age. Common underlying conditions thatlead to decreased myocardial contractility include myocardial dysfunction(especially from coronary atherosclerosis), arterial hypertension and valvulardysfunction (p. 622). Functional changes relate to inadequate tissue perfusion,dizziness, confusion, fatigue, exercise or heat intolerance, cool extremities,oliguria, sodium and fluid retention. Increased pulmonary venous pressure leads tocough, SOB and pulmonary edema. Increased systemic venous pressure may result ingeneralized edema and weight gain (p. 665). CAD: The most common heart disease inthe U.S. is atherosclerosis, which is an abnormal accumulation of lipid, or fattysubstances and fibrous tissue in the vessel wall. These substances createblockages or narrow the vessel in a way that reduces blood flow to the myocardium(p. 594). Functional changes depend on the degree of narrowing. Angina pectoris isrecurrent chest pain that is brought on by physical exertion or emotional stressand relieved by rest or medication (p. 595).--2-NSGCARE PLAN(Sample):2:1/06
Therapeutic/Multidisciplinary Treatment Plan: (Textbook)SourceSmeltzer and Bare, 2000CHF: Medical: Reduce workload of heart; increase the force and efficiency ofmyocardial contraction and eliminate the excessive accumulation of body water byavoiding excess fluid intake; controlling the diet and monitoring diuretic andangiotensin-converting enzyme (ACE) inhibitor therapy (p. 665). Nursing:Administer medications and assess the medication effects. Assess patient’s: intakeand 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 perform counseling and education concerning regular exercise, sodiumrestriction, and avoidance of excessive fluid intake, alcohol and smoking (p.668). Pharmacist: Review of medications used for treatment of CHF including ACEinhibitors, diuretic therapy, digitalis. Monitoring blood levels such as digoxin(in collaboration with MD and nursing) (p. 666). Registered dietitian: Nutritionassessment and counseling regarding sodium restriction, avoidance of excessivefluid intake and alcohol (p. 668). Respiratory therapist: Administer oxygentherapy based on the degree of pulmonary congestion and resulting hypoxia. Somepatients may need supplemental oxygen therapy during activity. Others may requirehospitalization and endotracheal intubation (p. 666). CAD: Prevention of CAD bycontrolling these risk factors is important: high cholesterol, cigarette smoking,hypertension and diabetes mellitus (p. 595). If CAD is associated with angina,medical management with drugs and control of risk factors is implemented todecrease the oxygen demands of the myocardium and to increase the oxygen supply(p. 598). Revascularization procedures include coronary artery bypass graft (CABG)surgery and percutaneous transluminal coronary angioplasty (PTCA, also known asballoon angioplasty) (p. 598). Medications include: Ntg, Beta blockers, calciumchannel blockers, antiplatelet and anticoagulants (pp. 598-599).Prescribed Treatments (as per physician’s orders) Oxygen: 3 LPM via N/C N/ARespiratory Treatment: IV Infusion: Diet: Feeding: NASHeparin lockRequires assistance BRP with assistanceBowel/Bladder: Hygiene: Activity: Other:Assist As tolerated with assist I & O; daily wts. Requires W/C for transportElevate HOB--3-NSGCAREPLAN(Sample):3:1/06

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