Bill Hill - good PDF

Preview

Summary

good...

Description

Adult Nursing Clinical Tool Student: Charlie Surita Introductory Information: Pt Initials: BH Allergies: NKDA Types of Reaction: N/A Code Status: Full Resuscitation

Activity Level: Bed rest

Safety/Precautions: Fall risk Admitting Diagnosis: AFib, heart failure History of Present Illness: Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills the past week. Myelodysplastic syndrome MDS) two months ago after a bone marrow biopsy He was diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of 6.9 and received a transfusion of one unit of PRBCs He was around grandchildren with colds two weeks ago. Bill woke up at 6 a.m. today feeling short of breath, and coughing harshly with clear sputum. His wife, who is a retired nurse, noted that he was much paler, took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months. Past Medical History (Diseases and Surgeries): N/A Relevant Family History: N/A Brief Description of Pathophysiology: Atrial fibrillation is an arrythmia that occurs in the atria, shortening the electrical impulses and loss of contractility in the atria Current Surgical Procedure/Date: N/A

Medication List (Ordered Routine Medications and PRN Medications Taken within the Last 24 Hours) Generic/Trade Dose/Route/Frequency Applicable Assessment Classification of Drug Name (for Hosp. Rx Only) Data or Labs and Why Your Patient is Receiving this Drug? Clopidogrel 75 mg PO daily Afib, heart failure Antiplatelet

Atenolol

50 mg PO daily

Bp, High hr

Beta blocker

Tamsulosin

0.4 mg PO daily

BPH

Alpha blocker

Lab Test

Normal Range

Laboratory Data High or Low Significance (cause of abnormal lab Abnormal specific to this patient-Why?) Value (Most Recent)

White Blood Cells

4,500-10,000

6.7

Low

MDS, infection

Hemoglobin

13.5-18

6.2

Low

MDS Clinical Care Plan 2

Hematocrit PT Partial Thrombin time PTT INR Sodium Potassium BUN Creatinine Magnesium Calcium Glucose Urine analysis Other Pertinent Lab Values Albumin

3.5-5

3.1

Low

Alkaline Phosphate

42-136

272

High

AST

8-35

144

High

Liver failure

ALT

10-35

171

High

Liver failure

Diagnostic Tests:

Xray: Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema Ultrasound: N/A CT Scan: Bilateral moderate pleural effusions with mild to moderate pericardial effusion MRI: N/A EKG: Atrial fibrillation ECHO: N/A Other: N/A

ADLs:

Ambulation: Assist Clinical Care Plan 3

Reposition: Independent Hygiene: Independent Transfer: Assist Eating: Independent Toileting: Assist Use Call light? Yes Express Needs? Yes Discharge Needs: F/U with PCP, Cardiology, Radiology within 24-48 hours; appointments scheduled before discharge home. Treatment options, learn how to take own pulse, home medication,

Education Provided to Patient: Educated patient about new medications; when, how and where to take. How to take pulse, when to call 911 or seek immediate care, when to contact specialty doctors, lifestyle adjustments, education on diagnosis

ANALYSIS: 1st Nursing Diagnosis: Decreased Cardiac Output Related to: Alteration in heart rhythm Manifested by:

1)ECG showing Afib 2) BP 104/60 3) Irregular HR

4) Tachycardia

PLANNING: Client Goal: Patient to have adequate cardiac output AEB bp, pr, and rhythm WNL

IMPLEMENTATION:

Nursing Interventions

1) Administer oxygen therapy as prescribed Clinical Care Plan 4

Rationale: Due to failing heart and respiratory distress oxygen is needed to maintain O2 level greater that 90% Evaluation: Patient is on continuous oxygen therapy and resting comfortably 2) Maintain patient on bedrest during moments of acute events to keep from worsening cardiac function Rationale: Temporary rest helps the heart recompensate Evaluation: Patient has been on bed rest with minimal ambulation 3) Monitor lab work; CBC, BNP, NA, K, ECG, xray of chest and lungs Rationale: Provides insight to patient status and any changes Evaluation: Patient results are still abnormal but improving

ANALYSIS: 2nd Nursing Diagnosis: Activity Intolerance Related to: Decreased cardiac function Manifested by:

1) generalized weakness

2) Hgb 6.2

3) Pallor

4) O2 sat 88%

PLANNING: Client Goal: Achieve increased activity per patient ability

IMPLEMENTATION:

Nursing Interventions

1) Provide calm and quiet environment Rationale: Helps patient to relax and avoid worsening health status Evaluation: Patient is able to vocalize stress level 2) Assess and document cardiac status by monitoring and measuring VS after activity Rationale: Assess health status and any increase in HR and oxygen demands that will aggravate weakness and fatigue Evaluation: Patient is able to recognize when to rest during ambulation Clinical Care Plan 5

3) Assess patient condition Rationale: To identify any abnormalities and changes of the body; edema, level of consciousness Evaluation: No additional worsening symptoms

Date/Time

Nurses Note

Clinical Care Plan 6

Clinical Care Plan 7...