Clinical Worksheet

Mary Richards
Jasgou1752
1. Date: 9/11/20
2. Initial: MA
3. Age: 82
4. Gender/Race: African American, female
5. Code status: full code
6. DX: congestive heart failure
7. Length of stay: 1 day- admitted 9/10/2020
8. Allergies: No Known
9. HCP: Dr. Idontknow
10. Consults: home health nurse should be contacted or case worker
11. Isolation: none
12. Fall Risk: yes
13. Transfer:
14. IV type: Lactated ringers IV @ 100 mL/hr through a 20-gauge IV catheter. Site
assessment WNL
15. IV location: right arm
16. Fluid/rate: LR infusing @ 100 mL/hr
17. Critical labs: HCT and Potassium, Digoxin lvls
18. Other services: N/A
19. Consults needed: N/A
20. Why is you pt. in the hospital: pt. Was bought today emergency Department when her
son found her confused and complaining of Trouble with her vision
21. Health Hx/Comorbidities: Patient Diagnose with heart failure 30 years ago In
hypertension 40 years ago

22. Shift Goals/ Pt. educational needs:

 Patient will demonstrate adequate cardiac output AEB VS all within normal limits .
Absent of dysrhythmias and no symptoms of failure
 Patient will participate in activities that reduce workload
 Patient will report decrease episodes of dyspnea and angina
 Patient will no longer have symptoms of nausea or vomiting episodes . Patient will have
no complaints of trouble with her vision
23. Path to discharge:
 Pt. understands Dx, treatment and risk factors.
 Pt. understands the importance of taking any medication as needed,
understanding adverse reactions, and follow up with hcp for appointment.
 Patient can demonstrate in return verbalize the signs of toxicity and when to
contact HCP
 Patient understands the dietary restrictions and food to avoid and foods to
increase in order to prevent hypo or hyper kalamia

24. Path to death or injury: Patient understands digoxin toxicity if left untreated can lead
to death

25. Alerts:
 Nutrition deflect
 Potassium/electrolyte imbalance
 Knowledge deficit of s/s of toxicity/med regimen
 Cardiac dysrhythmias
26. What assessments will focus on for this pt.
 Perform a cardia assessment
 Auscultate lung, heart and bowel sounds
 Perform a neuro assessment/changes
 Review lab work
27. Complications

 Electrolyte imbalance an intake potassium or not enough

 Dysrhythmias
 Digoxin toxicity
 Hyper or hypo kalamia

28. Nursing interventions:

 Limit sodium intake- monitor lab work in electrolytes including potassium
 monitor for signs of respiratory distress
 Monitor for signs of alter cardiac output
 Prevent infection and reduce cardiac demands
29. Managements of care: What need to be done for this pt. today?
 Monitor for signs of respiratory distress
o Provide pulmonary hygiene PRN
 o Admin 02 as prescribed
o Keep HOB elevated
o Monitor ABG values
 Monitor for signs I've altered cardiac output, including pulmonary edema
 Monitor for Brady cardia- characteristic ECG and heart sound changes
 evaluate fluid status
 Educate pt. about Dx
 Educate pt. about activities, safety and fall risk
 Educate pt. about ROM exercises
30. Priorities for managing the pt. care today
 Reduce the amt. of cellular injury
 Educating pt
31. What aspects of the pt. care can be delegated and who can do it?
o UAP or CAN- vitals/ADLS/ AMBULATION WHEN PT IS
STABLE/TURNING/CLEANING/BATHROOM USAGE-BEDPAN OR EMPTYING URINE
AFTER NURSE NOTES/DOCS AMOUNT