Nursing Care Plan related to Case 2

By Luvie Mevia Azzahra, 1706039282, Medical Surgical Nursing A

Case 2:

A man aged 47 years old, came to the polyclinic with the complaint of left chest
pounding, eyes bulging. Patient also complains his hands are tremoring, often
sweating, and feels hungry fast. Physical assessment shows the blood pressure
130/80 mmHg, body temperature 37dC, with a mild enlargement of the thyroid
gland. Laboratorium results shows:

Hb : 12,5 g/dL (12 – 16)

Leukocyte : 11.000/mmk (4000 – 11.000)
Neutrophil : 56% (40 – 70)
Lymphocyte : 40% (20 – 40)
Eosinophil : 1% (1 – 5)
Monocyte : 3% (2 – 8)
Thrombocyte : 420.000/mmk (150.000 – 450.000)
Total cholesterol: 179 mg/dL (<200)
Triglyceride : 105 mg/dL (<150)
Glucose : 100 mg/dL (80 – 140)
hTSH : 0,003 µU/mL (0,4 – 5,0)
Patient is advised to do T3, T4, and free T4 checking.

Assessment
Subjective Data
- Complains left chest pounding
Planning
Maintain adequate cardiac output for
tissue needs as evidenced by stable vital
signs, palpable peripheral pulses, good
capillary
refill, usual mentation, and absence of
dysrhythmias.
Nursing Care Plan
Diagnosis
Objective Data Risk for Decreased Cardiac Output
- Mild enlargement of thyroid gland
- BP 130/80 mmHg
Intervention
Independent
- Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.
- Monitor central venous pressure (CVP), if available.
- Investigate reports of chest pain and angina.
- Assess pulse and heart rate while client is sleeping.
- Auscultate heart sounds, noting extra heart sounds and development of gallops and
systolic murmurs.
- Monitor ECG, noting rate and rhythm. Document dysrhythmias.
- Auscultate breath sounds, noting adventitious sounds such as crackles.
- Monitor temperature, provide cool environment, limit bed linens and clothes, and
administer tepid sponge baths.

Assessment
Subjective Data
- Hands tremor
- Often sweating
Planning
Verbalize increase in level of energy.
Display improved ability to participate
in desired activities.
Observe for signs and symptoms of severe thirst, dry mucous membranes, weak and thready
pulse, poor capillary refill, decreased urinary output, and hypotension.
Collaborative
- Administer intravenous (IV) fluids, as indicated
- Administer medications, as indicated, such as: Beta-blockers, for example,
propranolol (Inderal), atenolol (Tenormin), nadolol (Corgard), and pindolol (Visken)
- Chest x-rays
- Provide supplemental oxygen (O2), as indicated.
Diagnosis
Objective Data Fatigue
-
Intervention
Independent
- Monitor vital signs, noting pulse rate at rest and when active.
- Note development of tachypnea, dyspnea, pallor, and cyanosis.
- Provide quiet environment, cool room, decreased sensory stimuli, soothing colors,
and quiet music.
- Encourage client to restrict activity and rest in bed as much as possible.
 - Provide comfort measures—judicious touch and massage and cool showers.
- Provide for calming diversional activities—reading, radio, and television.
- Avoid topics that irritate or upset client. Discuss ways to respond to these feelings.
- Discuss with SO reasons for fatigue and emotional lability.
Collaborative
- Administer medications, as indicated, such as sedatives and anti-anxiety agents.

References

Bulechek et al. (2013). Nursing interventions classification. 6th edition. Missouri: Elsevier

Doenges et al. (2010). Nursing care plans: guidelines for individualizing client care across the life span. 8th edition. Philadelphia: FA
Davis Company

Herdman, T. H. Kamitsuru, S. (2018). NANDA-I nursing diagnoses: definitions and classification. 11th edition. New York: Thieme