Pace University Lienhard School of Nursing Department of Undergraduate Studies Baccalaureate Nursing Program NURSING CARE PLAN NURS

360 Student Name: Melanie Dutton Date : November 3,2011 Clinical Rotation: White Plains Hospital Faculty: McDonald Nursing History Client's Initials: D.H. Age 76 Sex : Male Informant: Self Religion: Jewish Marital Status: Married Occupation: Retired

Admitting diagnosis: Atrial Flutter, Aortic Stenosis, Mitral Regurgitation Allergies: Penicillin Chief Complaint: Pt. stated: I have weakness in my right leg and back pain. My chest hurts on the right ever since I fell. History of present illness: Pt. past history includes an AV malformation with subarcachnoid hemorrhage, VP shunt in 1987, adenocarcinoma of splenic flexure, seizure disorder, right hemi paresis, and hyperlipidemia. Pt. has experienced constant pain in his leg and back without relief for the past month. Pt. reports having chest pain ever since he fell 2 weeks ago. Medications: (include name, dose, frequency, indication): Lopressor 12.5 PO Q12hr (treats high blood pressur). Senokot 2 tab PO QHS( stimulates bowel movements). Miralax 17g PO daily(stimulates bowel movements). Tylenol 650mg PO PRN (for fever). Digoxin 0.125mp PO daily(slows the heart rate for his atrial flutter) . Ultram 50mg Q6H PRN (for leg pain). Phenobarbital 30mg TID PO(treats seizures). Past medical and surgical history: Arterio-venous malformation of the brain post subarachnoid hemmorage, post right vp shunt in 1987. History of sub-acute bacterial endocarditis, left partial hemicolectomy in 1999, right inguinal hernia repair in 2001. Family History: History of cancer in two of his uncles. Parents died of natural causes. One younger brother who is still alive with diabetes. Personal and Social History: Pt used to smoked but quit 10 years ago. He denies drinking alcohol or drug use. He is married with his wife at home and has three grown children. Pt enjoys reading, walking in the park by his house, and being active in his senior club.

NURS 360 Nursing Care Plan Review of Systems: General: __________________________________________________________________ Skin: _____________________________________________________________________ HEENT: __________________________________________________________________ Neck: _____________________________________________________________________ Breasts: ___________________________________________________________________ Respiratory: ________________________________________________________________ Cardiovascular: _____________________________________________________________ GI: _______________________________________________________________________ GU: ______________________________________________________________________ Genital: ___________________________________________________________________ Neurological: _______________________________________________________________ Musculoskeletal: ____________________________________________________________ Peripheral vascular: __________________________________________________________ Other: (Endocrine, hematologic, psychiatric) _____________________________________ _________________________________________________________________________

Physical Examination: Vital signs: BP: 128/87 Hgt: 510 P: 76 R: 18 Temp: 97.3 Wgt: 170

Skin: Skin is smooth, warm to touch, to masses or lesions. HEENT: No earache or discharge, no sore throat, positive for hearing impairment, no blurring of vision, pupils round, equal, and reactive to light. Neck: No jugular vein distension, no bruits, neck is supple. Thorax: Tenderness upon palpation of the right side of the chest. Lungs: No rales, no rhonci, or wheezes present. Lungs are clear. Heart: Regular S1 and S2. Cardiovascular: (pulses) Peripheral Pulses 2+ Breasts : Smooth and no masses Abdomen: Soft and non-tender, non-distended. Positive bowel signs in all 4 quadrants. GU: No dysuria, positive for hematuria. Lower extremities: No lower limb edema, peripheral pulses 2+ and equal. Neuro: A+O X 3.

NURS 360 Nursing Care Plan 3 Lab and Diagnostic tests: (include results of pertinent tests for your client. Discuss how these tests and results pertain to your client) Pt. WBC count was 17.1 signaling infection, possibly a UTI. Pt. Potassium level is within normal limits but because of his heart conditions, his potassium level needs to be monitored. Pt. Creatine level was 24 signaling that the pt. is dehydrated. Pt. RBCS, Hemocrit, and Hemoglobin levels are within normal limits Pt. Troponin level is closely watched because of his cardiac condition Pt. Digotin is 2.2 and is closely monitored because of his atrial fib.

Pathophysiology: (Explain the pathophysiology of current diagnosis) Atrial Flutter- identified by recurring, regular, sawtooth-shpaed flutter waves that originate from a single ectopic focus in the right atrium. Atrial flutter rarely occurs in a healthy heart. Mitral Valve Regurgitation- mitral valve function depends on the integrity of mitral leaflets, papillary muscles, LA, and LV. Any defect in these structures can result in regurgitation. Mitral valve regurgitation blood flow to flow backward from the left ventricle to the left atrium because of incomplete valve closure in systole. Aortic Stenosis- aortic stenosis in older adults is caused by rheumatic fever or senile fibrocalcific degeneration that has an etiology similar to coronary artery disease. Aortic Stenosis causes an obstruction of from the left ventricle to the aorta during systole. It leads to a reduce in cardiac output which leads to heart failure. Nursing Diagnosis(es): List all nursing diagnosis pertinent to your client in order of priority

1. Decreased Cardiac output related to underlying condition 2. Ineffective Tissue perfusion related to underling condition 3. Risk for Falls 4. Knowledge Deficit 5. Imbalanced Nutrition: Less than body requirements 6. Activity Intolerance related to diminished cardiac output

NURS 360 Nursing Care Plan Expected client outcomes: For the top two priority nursing diagnoses, describe the expected outcomes 1. Pt. will demonstrate adequate cardiac output as evidenced by BP, HR, and rhythm within normal parameters. 2. Pt. will not experience any side effects or adverse reactions to cardiac medications 3. Pt. will demonstrate adequate knowledge about their disease and process by discharge 4. Pt. will verbalize knowledge of their treatment regimen, including appropriate exercise and medications, their actions and possible side effects 5. Pt. Client will demonstrate adequate tissue perfusion AEB blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without dyspnea, syncope or chest pain, and increased urine output

Nursing Diagnosis 1. Decreased Cardiac Output

Nursing Interventions and rationale 1. Assess client for signs and symptoms of heart failure and decreased cardiac output Listen to heart sounds, lung sounds, and assess peripheral pulses 2. Monitor I+O hourly Decreased cardiac output results in decreased renal perfusion and decreased cardiac output 3. Check BP, Pulses, and condition before administrating cardiac medications Assessing vitals prior to medication administration can reduce the chance of adverse effects Notify physician if BP it too low 4. Assess for signs and symptoms of adverse medication effects By assessing for early signs of adverse reactions serious complications from these medications can be avoided 1. Monitor skin conditions at least once a day for color or texture changes, or lesions. Determine whether the client is experiences loss of sensation or pain. Systematic inspection can identify impending problems early

2. Ineffective Tissue Perfusion

NURS 360 Nursing Care Plan

5 2. Monitor peripheral pulses. If there is a new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately. 3. Monitor neuro status frequently Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia. 4. Administer supplemental oxygen Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. 5. Position Patient with head of bed 45 degrees (if tolerated). Promotes better lung expansion and improved gas exchange.

NURS 360 Nursing Care Plan 6 Evaluation: Describe how you would evaluate the patients progress or achievement of each expected outcome #1 Pt. will Pt. will demonstrate adequate knowledge of his disease by discussing demonstrate his disease and process appropriately with nurse by the end of adequate discharge knowledge of disease #2 Pt. will demonstrate adequate cardiac output #3 Pt. Client will demonstrate adequate tissue perfusion Pt. will demonstrate adequate cardiac output by having a BP, HR, and Rhythm within normal parameters

Pt. will demonstrate adequate tissue perfusion by having BP, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without dyspnea, syncope or chest pain. He will also have an increased urine output

Discharge Plan: Complete the following for your client Previous community resources: Unknown Community resources needed for this discharge: Social worker and nurse need to work together to establish the pts. needs. Pt. may need aid several hrs a day to help with ADLS. Discharge teaching plan: Advise Pt. and caregiver regarding adverse reactions to medications and methods for monitoring for them Instruct pt. and caregiver to monitor for weakness, edema, and difficulty breathing Instruct pt. and caregiver on the importance of maintaining sufficient cardiac output and tissue perfusion

Research question: How does a decrease in cardiac output relate to a Pt. risk for falls? Reflection: My Pt. a 76 y/o male with a history of cardiac problems, main diagnosis were decreased cardiac output and ineffective tissue perfusion. Through my appropriate nursing interventions and expected outcomes the client should be able to lead a much more safer and healthier lifestyle.
Nursing Care Plan Format.doc KTH 8/2007;revised 9/8/1