Care Plan

Student: Alexis Gibson Date: 02/10/2020

Course: NSG-320CC Instructor: Professor McNiff

Clincial Site: Banner University Hospital Client Identifier: H.B. Age: 62 years
old

Reason for Admission:

Patient H.B. was admitted for shortness of breath.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Diagnoses: Presented:
Diastolic heart failure exacberation with fluid overload. SOB, fatigue, upper/lower body edema/swelling on both legs and
feet as well as right hand (not sure if pitting or not), cough
Pathophysiology:
occasionally, etc.
Heart failure develops in response to myocardial insult. The heart is then
Expected:
inable to provide enough blood to meet the oxygen needs of the tissues
and organs. When the cardiac output is decreased then tissue perfusion, “Weakness, fatigue, anxiety, depression, dyspnea, orthopnea,
impaired gas exchange, fluid volume imbalance, and functional ability nocturia, fluid retention, etc.” (Harding, Roberts, Reinisch, Hagler,
will all decrease. In diastolic heart failure, the left ventricle is not able to & Kwong, 2020, p. 739).
fill up with blood appropriately. If the ventricle is no filling with enough
blood, then the amount of blood being pumped into the body is decreased.
This then can cause shortness of breath (SOB) along with other
symptoms. Patient H.B. presented with SOB (Harding, Roberts, Reinisch,
Hagler, & Kwong, 2020).
© 2019. Grand Canyon University. All Rights Reserved.
 Assessment Data
Subjective Data: Patient is doing well and will be discharged in the next day or so. Patient is off of oxygen and is not complaining of SOB.
VS: T : 36.8 degrees Celsius Labs: Diagnostics:
BP: 154/69  WBC: 7.1  Chest PA + LAT on 02/07/2020:
HR: 64  RBC: 4.1 Diffuse pulmonary vascular prominence, small
 HGB: 10.3 pleural effusions, and likely suggestive of edema.
RR: 18  HCT: 33.4 Minimal left basilar atelectasis/consolidation.
O2 Sat: 95  Platelet: 278
 Glucose: 112  Ultrasound Venous Duplex (LE) Bilateral on
Pain: 0 02/07/2020:
 BUN: 41 (high)
 Creatinine: 2.09 (high) No evidence of deep vein thrombus in wither
lower extremity.
 Sodium: 137
 Potassium: 4.1
 Nuclear Lung Vent Perf on 02/07/2020:
 Calcium: 8.7
Negative lung imaging study,
ventillation/perfusion scan, no significant focal
perfusion abnormalities and no scintigraphic
evidence of pulmonary embolism.

Assessment: Orders:
Neuro:  Measure I/O
 Cardiac monitoring
 LOC = Alert/Responsive
 Monitor VS
 A/O x 4
 Educate on VTE
Respiratory:  Basic metabolic panel (includes GFR)
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  Unlabored  CBC (with differentials)
 Left lower breath sounds = diminished  Continue to place in observation
 Left upper breath sounds = clear  Check blood sugar
 Right lower breath sounds = clear  Monitor daily weight
 Right upper breath sounds = clear  Reinforce diet (low sodium)
Cardiovascular:
 Pulses = +1 (palpable, thready)
 Normal sinus rhythm
 Capillary refill is less than 2 seconds
GI/GU:
 Abdomen = protuberant, firm
 No GI symptoms
 Edema (upper/lower exremities)
 Voiding, no difficulties
Integumentary:
 Skin color is normal for ethnicity, warm
 Some lesions present on both calves

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 Medications
ALLERGIES:
Theophylline, Theo-Dur, codeine, hydrALAZINE

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect
amLODIPine 10 mg = 2 PO Once daily Used to manage hypertension,
tabs angina pectoris, and vasospastic
angina. This patient is receiving
this medication for
management of hypertension
(Vallerand, Sanoski, & Deglin,
2019).
Bumetanide (Bumex) 1 mg = 2 tab PO BID Used to treat edema due to
heart failure, hepatic disease, or
renal impairment. Patient is
taking this medication to treat
edema due to heart failure
(Vallerand, Sanoski, & Deglin,
2019).
Metroprolol 100 mg = 2 PO BID Used to prevent MI and
tab decrease mortality in patients
with recent MI. Decreases BP
and heart rate. Patient is taking
this medication for
hypertension (Vallerand,
Sanoski, & Deglin, 2019).
Clopidrogel (Plavix) 75 mg = 1 PO Once daily Used to reduce atherosclerotic
tab evens like MI, stroke, vascular
“Peripheral edema, angina,
bradycardia, palpitations, etc.”
(Vallerand, Sanoski, & Deglin,
2019, p. 148).
“Hypotension, hyperglycemia,
hypokalemia, hyponatremia,
hypovalemia, etc.” (Vallerand,
Sanoski, & Deglin, 2019, p.
234).
“Fatigue, weakness, nightmares,
blurred vision, dry mouth, etc.”
(Vallerand, Sanoski, & Deglin,
2019, p. 840).
“Chest pain, edema, back pain,
fever, cough, dyspnea, etc.”
Considerations
- “Assess signs of HF
- Monitor BP/HR
- Monitor I/O ratios”
(Vallerand, Sanoski, &
Deglin, 2019, p. 148).
- “Monitor BP and
pulse before and during
administration
- Monitor electrolytes,
renal and hepatic
funciton, serum
glucose, and uric acid
levels before and
periodically during
therapy” (Vallerand,
Sanoski, & Deglin,
2019, p. 235).
- “Monitor BP, ECG,
and pulse frequently
during dose adjustment
and periodically during
therapy
- Monitor VS
- Monitor I/O ratios and
daily weights”
(Vallerand, Sanoski, &
Deglin, 2019, p. 840).
- “Assess patient for
symptoms of stroke,
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 death in patients at risk for such (Vallerand, Sanoski, & Deglin, peripheral vascular
events. Patient is taking this 2019, p. 331). disease, or MI
medication as a blood thinner periodically during
(Vallerand, Sanoski, & Deglin, therapy
2019). - Monitor bleeding time
during therapy”
(Vallerand, Sanoski, &
Deglin, 2019, p. 331).
Insulin Lispro 6 units = SQ TID with Used to control hyperglycemia “Hypoglycemia, swelling, - “Assess for symptoms
0.06 mL meals in patients with type 1 or type 2 allergic reaction, erythema, etc.” of hypoglycemia
DM. Patient is taking this (Vallerand, Sanoski, & Deglin, - Monitor body weight
medication for controlling type 2019, p. 697). periodically”
2 DM (Vallerand, Sanoski, & (Vallerand, Sanoski, &
Deglin, 2019). Deglin, 2019, p. 698).
heparin 5000 untis = SQ Q8 hours Used to prevent thrombus “Alopecia, bleeding, fever, - “Assess for signs of
1 mL formation and prevention of hypersensitvity, rashes, etc.” bleeding and
extension of existing thrombi. (Vallerand, Sanoski, & Deglin, hemmorhage
Patient is using this for the 2019, p. 630). - Monitor patient for
intended use. hypersensitivity”
(Vallerand, Sanoski, &
Deglin, 2019, p. 631).

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for ineffective breathing pattern related to shortness of breath and fluid overload.
1. Patient will use 1. Teach the patient deep 1. “This will allow the 1. Patient is able to
Patient will be able to effective breathing breathing and couhging patient to participate in breathe effectively and
breathe effectively and will techniques. exercises maintaining health status does not experience
not experience SOB by the and improve ventilation” SOB.
time she is discharged from 2. Patient will remain free 2. Position client for (Phelps, 2017, p. 44).
the hospital. of s/s of hypoxia. maximum lung expansion. 2. Patient does not show
2. “This will promote lung any signs or symptoms
3. Patient will remain free 3. Administer oxygen as expansion and ventilation” of hypoxia.
of dyspnea. ordered. (Phelps, 2017, p. 44).
3. Patient is free of
3. “This will reduce the dyspnea and does not
risk of hypoxemia and need the ordered
relieve respiratory distress” oxygen.
(Phelps, 2017, p. 44).
Secondary Nursing Diagnosis:
Risk for activity intolerance related to shortness of breath and diastolic heart failure.
1. Patient will identify a 1. Teach energy 1. “These measures reduce 1. Patient is able to
realistic activity level to conservation for activities. cellular metabolism and identify realistic activity
Patient will be able to
maintain. oxygen demand” (Phelps, levels to maintain.
resume to daily activities
2017, p. 5).
without feeling fatigued by 2. Patient will identify 2. Teach s/s of activity
the time of discharge. methods to reduce activity intolerance (monitor 2. Patient is able to
intolerance. physiologic responses to 2. “This will help to identify methods to reduce
increased activity). measure responses and see activity intolerance.
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 3. Patient progresses any patterns” (Phelps,
activity to highest 3. Assist to develop a plan 2017, p. 5). 3. Patient is able to
tolerance level. for increasing activity to progress activities to
highest tolerance level. 3. “Participation in highest tolerance level.
planning may encourage
patient compliance with
the plan” (Phelps, 2017, p.
5).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

References

Harding, M., Roberts, D., Reinisch, C., Hagler, D., Kwong, J. (2020). Lewis's Medical-Surgical Nursing. Retrieved

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 from https://pageburstls.elsevier.com/#/books/9780323551496/

Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer. ISBN-13: 9781496347817.

Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA: F.A. Davis

Company.