NURSING CARE PLAN

Patient: _EC
Medical Diagnosis: ___Acute respiratory failure_________
Co-Morbidities: _ DM, high cholesterol, CAD, MI with stent, severe aortic stenosis, stomach CA w/ partial gastrectomy in 2007, CHF w/
AICD placement

Nursing Supporting Assessment Data Nursing Interventions Expected Evaluation

Diagnosis Patient
Outcome

SUBJECTIVE: Monitor:
 c/o SOB  VS (BP, HR, orthostatic BP), EKG, Adequate
Perfusion  orthopnea echo, labs (trop, BNP, CBC, Na/K) cardiac output
 paroxysmal nocturnal  Heart sounds, irregular heartbeat, as evidenced
(Decreased dyspnea extra HS, murmurs of:
cardiac  S/S of decrease cardiac output:  BP control  Last set of VS
output r/t OBJECTIVE: fatigue, dyspnea, chest pain, edema, @ 1600: BP
impaired  BP 136/79 HR 90 @ SOB at rest or upon exertion,  Pulse rate 144/79, HR 88
cardiac 0700; BP 154/85 HR 89 orthopnea, PND, weight gain, JVD, and rhythm HR is
function) @ 1015; BP 144/79 HR palpitations, lung crackles, coughing, WNL for maintained
88 @1600 clammy skin, skin color changes patient WNL,
 EKG shows sinus  Strict I/O however,
tachycardia with Manage:  Ability to need to
ventricular premature Non-pharmacological interventions: tolerate continue Lasix
complexes and  Elevated HOB, DVT/PE preventions ADLs to lower BP
anteroseptal MI (SCDs, compression stocking) without  SOB upon
 EF 35-40%  Administer oxygen PRN per MD order symptoms exertion
 elevated troponin 0.153  Minimize stressors (provide restful of dyspnea, during PT eval
 elevated pro BNP 11650 environment, dim lights, close door) SOB goal isn’t
Pharmacological interventions: met, continue
 S1, S2 irregular rhythm
 Lasix promotes diuresis of extra fluids, Lasix
w/ murmur
 Ankle edema 2+ in lower decreases pulmonary edema and
extremities due to CHF pedal edema
 CXR showed infiltration  ASA, Eliquis, Statin: prevent blood
consistent with clots, especially around the stent, and
pulmonary edema due to lowers cholesterol level to prevent
fluid regurgitation another MI
secondary to CHF  Amiodarone works simultaneously with
  Strong R pedal pulse AICD to control heart rate and rhythm,
and radial pulses lower chance of another Vtach
bilaterally 2+, weak L occurrence
pedal pulse 1+ Teach:
 Cap refill <3 sec on all  Report s/s of CHF, MI
extremities, thickened  Compliance with medications
pale nail beds  Low sodium diet
 No JVD  Daily weight monitoring
 On Amiodarone, AICD  Stress reduction
for dysrhythmia,  Energy conservation
Apixaban and ASA,
statin, and stent for MI
Nursing Supporting Assessment Data Nursing Interventions Expected Pt Evaluation
Diagnosis Outcome

SUBJECTIVE: Monitor:  Maintain  HR

 “I peed a lot”  VS normal maintained in
 “I don’t want to eat  s/s of F&E imbalance such as resp failure, sinus heart normal rate
breakfast, but I’ll drink arrhythmias, edema, muscle weakness, rhythm with with irregular
Fluid and the juice” AMS a regular rhythm at
electrolytes  Strict I/O, daily weight rate times
OBJECTIVE:  Labs: K, Na, Cl, BUN, CMP  Goal isn’t met:
 BP 136/79 HR 90 @ 0700;  Effectiveness of Lasix through BP, I/O,  Decrease Edema still 2+
BP 154/85 HR 89 @ 1015; weight edema  K WNL; Na
BP 144/79 HR 88 @1600 Manage: low; BUN high
 Ankle edema 2+ in lower  Maintain  cont to
extremities Non-pharmacological interventions: normal trend
 Intake: 688; Output:1650 (-  low sodium diet serum K,  End of shift O:
962)  encourage adequate bed rest Na, BUN 200 while
 Labs: Na/K 135/4.4 (5/1)   administer fluids with caution I:410  goal
134/4.2 (5/2)  Adequate isn’t met (due
 BUN:21 (5/1) – 22 (5/2) Pharmacological interventions: urine to not
 Wt: 64.1kg on 5/1, no  Lasix for diuresis output receiving
change today 5/2 considering Lasix during
 2+ Strong R pedal pulse and Teach: pt on Lasix the shift bc
radial pulses bilaterally, 1+  Medication teaching: drug name, MD ordered
weak L pedal pulse dosage, purpose, SE  Decrease only 1 dose of
 CXR shows pulmonary in weight Lasix, called
 Importance of low sodium diet
edema, coarse crackles in due to MD to put in
 Report s/s of hyper/hypokalemia
bottom of both lungs  diuresis order for
including muscle twitching/weakness,
accumulated fluid in lungs routine Lasix,
n/v/d, abnormal HR, cramping
 On Lasix for diuresis  Warning signs of dehydration: thirst continue to
and decreased urine output, dry trend)
mouth, muscle cramps, n/v, light h/a,  Goal not met,
orthostatic hypotension no change in
weight