Carl Shapiro Nursing Care Plan PDF

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Carl Shapiro Nursing Care Plan- VSim...

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Pace University Lienhard School of Nursing Nursing Care Plan Name: Pt's Initials: C.S. Age: 54 Gender: Male Diagnosis: angina- coronary artery disease Assessment Pathophysiology Goals

Chief Complaint: chest pain, diaphoresis, and shortness of breath

Orders

Subjective: Patient said he was in no pain

He was treated in ER with Aspirin and to doses of sublingual nitroglycerin. Chest pain improved with nitroglycerin administration

Patient states “I don’t feel well” right before his code

Normal Saline at 75 ml/hour

He stated when he was admitted the pain felt like “an elephant sitting on his chest”

Oxygen per nasal cannula to keep saturation greater than 92%

Display reduced tension, relaxed manner, ease of movement Verbalize relief/control of chest pain within appropriate time frame for administered medications

Monitor ECG Monitor lab biomarkers results

3 lead ECG Pain is 0/10 after the second dose of nitro Objective: Initial assessment Heart Rate: 82

Morphine 2 mg IVP for relief of chest pain/pressure during Nitro titration. May repeat x 1 dose.

Check for proper oxygen level Provide patient education Patients heart rate will return to regular

BP: 125/74

Labs: CPK-MB, Troponin, CBC, MPC

RR: 12

Chest Radiology

Patient will continue to have no pain

SpO2: 98%

Assessed patients IV.

Patients’ oxygen will

Date: 3/12/21 Nursing Diagnosis

a. Deficient fluid volume r/t inadequa te fluid volume intake a. Deficient

Nursing Interventions

Rationale

Monitor any changes in blood pressure, respirations and pulse

Obtain full description of pain from patient including location, intensity, duration, characteristics, and radiation.

The patient went into ventricular fibrillation (was not breathing and no heart rate). CPR and shock were given and patient began breathing again

Note any Electrocardiographi c changes

Monitor lab results Monitor pain level frequently and administer medication ordered if the pain returns

Patient came int ER complaining of chest pain and heaviness and the patient was given Nitroglycerin and aspirin and the pain was relived

Evaluation

Short- term goal: Patients heart rhythm returns back to normal. Evaluation: patient was administered a shock and is now being watched and monitored closely

Short- term goal: administer CPR and wait for code team to arrive Evaluation: patient was given CPR and a shock and patient resumed breathing Long- term goal: patients’ pain will be monitored and not return. Evaluation: Provides baseline for comparison to aid in determining effectiveness of therapy, resolution

remain over 95% Temp: 99F

Second Set of Vital signs Np pulse

Auscultated heart sounds. Activated code team after patient developed ventricular fibrillation

No breathing EKG shows V fib

Started CPR at 30:2 ratio with chest compressions

SPo2 -Final Assessment Heart rate: 80irregular Patient is breathing again SpO2: 97% HPI No known allergies indicated

Placed backboard under patient Attached defibrillator pads Turned on AED Delivered shock as directed by AED

Verbalizes reduction of anxiety/fear Demonstrates positive problemsolving skills

fluid volume r/t inadequa te fluid volume intake

Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen).

Acute Pain related to cardiac ischemia

Continued compressions Patient resumed breathing and I stopped CPR

Instruct patient to report pain immediately. Provide quiet environment, calm activities, and comfort measures. Approach patient calmly and confidently.

Risk for decreased cardiac output related to left ventricular failure Risk for ineffective peripheral tissue perfusion related to decreased cardiac output Ineffective Tissue Perfusion: cardiopulmonary related to interruption of flow (arterial)

Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen).

There are lifestyle changes that can help the patient prevent this again, COPD can be caused from external factors Some risk factors are called modifiable, because you can do something about them.

and progression of problem. Long- term goal: educate the patient about lifestyle changes to prevent further cardiac issues, and how to treat his COPD Evaluation: Patient education was given

Activity Intolerance related to Imbalance between oxygen supply/demand

Fear/Anxiety related to change in health AEB uncertainty, feelings of inadequacy EP 1/2019; Nursing Care Plan single sheet...