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NUR 3846 Anne Arundel Community College Heart Failure Care Plan Paper

NUR 3846

Anne Arundel Community College

NUR

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I’m studying for my Nursing class and need an explanation.

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I want a care plan from this study care.

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Weekly Clinical Write Up (to be completed by the end of your clinical day) STUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES___ Primary MEDICAL DIAGNOSIS: ______________________________________Secondary __________________________________ Past Medical History Assessment Data: Physiological Psychological Socioeconomic Cultural Spiritual Pharmacology: Home: Hospital Diagnostic Data: Laboratory studies 1/2014 ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Objective/outcome . 1/2014 ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Objective/outcome . 1/2014 Weekly Clinical Write Up (to be completed by the end of your clinical day) STUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES___ Primary MEDICAL DIAGNOSIS: ______________________________________Secondary __________________________________ Past Medical History Assessment Data: Physiological Psychological Socioeconomic Cultural Spiritual Pharmacology: Home: Hospital Diagnostic Data: Laboratory studies 1/2014 ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Objective/outcome . 1/2014 ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Objective/outcome . 1/2014 Weekly Clinical Write Up (to be completed by the end of your clinical day) STUDENT: Jane Doe NURS 349 PATIENT INITIALS: M. C ROOM NUMBER___808_ DATES: _10/03/2017_ PRIMARY MEDICAL DIAGNOSIS: Acute Kidney Injury/ Acute Ischemia SECONDARY DIAGNOSIS: Change in mental status/level of Consciousness. Past Medical History: Hypertension Stroke Dementia Gout Acute Kidney Injury Assessment Data: Physiological: General: The client was brought to the hospital from his home in with an ambulance after a fall. The Client is 90 years old and lives by himself; but has a caregiver who comes around every day to care for him. The Client is a full code, has no known medication allergy, and is confused. Respiratory: Respirations 22 BPM, SpO2 98% via room air. Friction rub heard on auscultation. No adventitious breath sounds. No use of accessory muscles and dyspnea noted. CV: Temp 97.8 F, PR 104 BPM, BP 159/79 mmHg. S1-S2 heart sounds regular, no gallops, murmurs, no and friction rubs heard on auscultation. No complaints of chest pain. Capillary refill < 2 sec. Bilateral pedal pulse was normal +2, and bilateral radial pulses were normal +2. 22-guage IV on Right Internal Jugular Vein. Electrocardiogram shows premature ventricular complex GI: The client’s oral mucosa was intact, moist and pink. Bowel sounds are hyperactive on all four quadrants. Abdomen not obese, no tender or re-bound tenderness, and non-distendable. The Client is NPO because of aspiration precautions, and client has an NG tube in place. No vomiting noted, diarrhea, or constipation. The client is incontinent of bowel. GU: No Foley catheter, urine is concentrated as seen on client’s diaper. The client is incontinent of the bladder, with no difficulties in voiding. No painful urination, and no foul-smelling urine noted. Integumentary: Skin is intact, no tenting, color is consistent with African American race, skin warm and dry to touch. No rashes, open areas, or blisters noted. Client has a 22 gauge iv on the right upper arm and left lower leg. Reproductive: client is a widower has no children, but has a caring and loving family Musculoskeletal: Bed Rest because of agitation and confusion. Weak muscle tone noted (atrophy). ROM was within normal limits, pedal pulses present, client can move all extremities, and no stiffness noted. Psychological: Patient has dementia, and is confused. Patient is alert and oriented x1 (to person) Developmental (Erikson’s): Integrity vs despair: M.C is very independent, he lives a successful life; but he is despair, because of his medical condition which has left him dependent and incapable to take to care of himself. Socioeconomic: Patient was a smoker and does not drink alcohol. According to patient’s history, he did not use any hard drugs. The patient is a widower with no biological living children. Cultural: Patient is an African American. Spiritual: Patient is a Christian and a catholic and attends mass every Sunday and participated in church activities before his sickness. Pharmacology: Home: Irbesartan 75mg oral, Bumex 0.5mg oral, Carvedilol calcium 5mg oral, Digoxin 125 mg oral, Lipitor 75 mg oral, vitamin D3 1 mg oral. Hospital: Aspirin 325mg PO, IV sodium chloride, ceftriaxone, potassium chloride, Enalapril, ondansetron, epinephrine, enoxaparin sodium, lidocaine, magnesium sulphate. Diagnostic Data: MRI of the brain without contrast, MRA of the brain without contrast, Chest x-ray, EKG, MRA of the neck without contrast, Barium swallow. Laboratory studies: BUN: 40MG/DL, H&H 14-45, K+ 3.1, CRT 2.4, Ca 8.7, Mg 2.1, Na+ 155, cholesterol 249, LDL 160. ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Objective/outcome Neuro: Client is alert and oriented X1 to person, Speech is not within normal limits because client has aphasia. Client’s pupil is equal, round, reactive to light and accommodation (PERRLA). Client’s motor and sensory skills are not intact (client does not follow commands). Upper extremity movement is within normal limits, no facial drooping, no response to verbal stimulus and client is in distress. Respiratory: Respirations 22 BPM, SpO2 98% via room air. Friction rub heard on auscultation. No adventitious breath sounds. No use of accessory muscles and dyspnea noted. CV: Temp 97.8 F, PR Altered mental status related to dementia, as evidenced by confusion, restlessness, and inability to follow commands. risk for aspiration related to absence of protective mechanisms, as evidenced by inability to swallow. Risk for impaired skin integrity related to immobility as evidenced by urine and bowel incontinence. The nurse should assess client’s LOC and changes in behavior to provide baseline 1) outcome me. client does for comparison with ongoing not experience any injuries assessment findings. (Gulanick or falls throughout my &myers 2014 p.480). shift. 2) A staff member should stay 2) outcome met. client at client’s bedside, to protect undergoes complete client from harm and falling. diagnostic workup to rule (Gulanick &myers 2014 out any reversible cause of p.480). confusion. 3) The nurse should monitor 3) outcome met. Clients client’s neurologic status on a cognitive abilities, regular basis to detect any behavior, and self-care improvement or decline in status was assessed. client’s neurologic function. 4)Outcome met. Client was (Gulanick &myers 2014 provided with a one on one 1)client will tolerate NG tube p.481). sitter by his bedside. feeding by the end of my 84) The nurse should use hour shift. appropriate safety measures to 2) By the end of my 8-hour protect patient from injury. shift, client’s respiratory Physical restraints should be secretions will be clear and avoided to prevent agitating odorless. the client. (Gulanick &myers 1) Outcome met client 3) Measures will be taking to 2014 p.481). temperature and prevent aspiration by the end of WBC count remain my shift. within normal parameters. 4) no adventitious breath 2) Outcome met client sounds will be heard during respiratory auscultation. secretions remain clear and odorless. 1. Patient won’t experience injury by the end of my 8hour shift. 2. Patient will start to participate in activity of daily living (ADLs) by the end of my shift. 3. Patient will be calm by the end of my shift. 4. Patients neurologic status won’t deteriorate. 104 BPM, BP 159/79 mmHg. S1-S2 heart sounds regular, no gallops, murmurs, no and friction rubs heard on auscultation. No complaints of chest pain. Capillary refill < 2 sec. Bilateral pedal pulse was normal +2 and bilateral radial pulses were normal +2. 22-guage IV on Right Internal Jugular Vein. Electrocardiogram shows premature ventricular complex. GI: The client’s oral mucosa was intact, moist and pink. Bowel sounds are hyperactive on all four quadrants. Abdomen not obese, no tender or re-bound tenderness, and nondistendable. Client is NPO because of aspiration precautions, and client has an NG tube in place. No vomiting noted, diarrhea, or constipation. The client is incontinent of 5) Clients bowel sounds will be 1)The nurse should assess hyperactive on all four client’s respiratory status quadrants. every 4 hours for signs of possible aspiration such as; 6) clients’ temperature and increased respiratory rate, WBC will remain within cough, sputum production, or normal limits. diminished breath sounds. (Gulanick &myers 2014 p.481) 2) The nurse should monitor and record vital signs to detect signs of aspiration or impaired 1) patient will experience no gas exchange due to skin breakdown. aspiration. (Gulanick &myers 2) Patient will maintain muscle 2014 p.481). strength and joint ROM. 3) The nurse should encourage 3) Patient will sustain adequate client to cough and food and fluid intake. expectorate sputum to 4) Patient will maintain mobilize secretions. (Gulanick adequate skin circulation. &myers 2014 p.482). 5) patient will communicate 4) The nurse should auscultate understanding of preventive for bowel sounds every shift skin care measures. and report changes. Delayed 6) Patient and family members gastric emptying and elevated will corelate risk factors and intragastric pressure may preventive measures. promote regurgitation of stomach contents. (Gulanick &myers 2014 p.482). The nurse should inspect patient’s skin every shift; document skin condition and report any status changes. Early detection of changes prevents or minimizes skin breakdown. (Gulanick &myers 2014 p.794) 3) Outcome not met. Auscultation of client’s lungs reveal bilateral crackles. 4) Outcome met. Auscultation of bowel reveals normal hyperactive bowel sounds on all four quadrants. 1)outcome met. Client’s skin remains intact. 2) Outcome met. Client did not show any sign of poor skin circulation such as redness and darkened areas on the skin. 3) Outcome met. Client did not show any signs or symptoms of contracture or muscle atrophy. 4) Outcome not met. Client is unable to communicate understanding of preventive skin care methods. 5) Outcome partially met. Client received adequate fluids, but not adequate food intake. bowel. GU: No Foley catheter, urine is concentrated as seen on client’s diaper. The client is incontinent of bladder, with no difficulties in voiding. No painful urination, and no foul-smelling urine noted. Integumentary: Skin is intact, no tenting, color is consistent with African American race, skin warm and dry to touch. No rashes, open areas, or blisters noted. Client has a 22 gauge iv on the right upper arm and left lower leg. Reproductive: client is a widower has no children, but has a caring and loving family. Musculoskeletal: Bed Rest because of agitation and confusion. Weak muscle tone noted (atrophy). ROM was within normal limits, pedal pulses present, client can move all 2) The nurse should change patient’s position at least every 2 hours; follow turning schedule posted at bedside. Monitor frequency of turning. These measures reduce pressure on tissues, promote circulation, and avoid skin breakdown. (Gulanick &myers 2014 p.794) 3) The patient’s linen should be kept dry, clean, and free from wrinkles or crumbs. Change wet bed linens and incontinence pads immediately. Dry, smooth linens help prevent excoriation and skin breakdown. (Gulanick &myers 2014 p.794) extremities, and no stiffness noted. ...
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Weekly Clinical Write Up(to be completed by the end of your clinical day)

STUDENT____________________________________PATIENT INITIALS_W.M_ROOM NUMBER________DATES 03/30/2020___
Primary MEDICAL DIAGNOSIS: Heart Failure

Secondary: myocardial infarctions

Past Medical History
Type 2 diabetes
Hypertension,
Hyperlipidemia and
Coronary artery disease

Assessment Data:
Physiological
General: The client is a white woman aged 68 years. She has a past medical history of hypertension, diabetes type 2, hyperlipidemia and coronary
artery disease. R.K also has a history of mycocardial infarctions for several years. She smoked two packs of cigarettes for 30 years, but quitted
after developing her first MI 4 years ago. The patient is overweight in most of her life and lacked regular exercises apart from household duties.
The current drug regimen includes ezetimible/ simvastatin (Vytorin) 10/40mg/day, indapamide (Lozol) 2.5 mg/day and losartan (Cozzar) 50
mg/day. R.K has scheduled an appointment with the nurse practitioner at the local care clinic.
Respiratory: Respirations 23 BPM, SpO2 98% through room air. No friction rub was recorded on auscultation. No adventurous breathing sounds
or use of accessory muscles identified.
CV: Temp 98.2 F, PR 10 PR 107 BPM, BP 168/71 mmHg. S1-S2 heart sounds are irregular. Extra heart sounds heard from the blood vessels
when a stethoscope is used. Abnormal sound of blood ...

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UCLA

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