IHUMAN PATIENT ASSESSMENT PLAN OF CARE. Latest 2021

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PLAN OF CARE IHUMAN PATIENT ASSESSMENT STUDENT: Date of Care: 3/27/2021 Age: 69 Gender: M Resuscitation Status Allergies none Reason for Admission: Heart Failure Exacerbation Medical ... Diagnoses: stage II right sided heart failure Surgeries/Procedures and Dates: Past medical history Coronary artery disease, Hyperlipidemia, Myocardial infarction, Hypertension, Stage 2 Right sided Heart failure Current Orders: Diet_low sodium (2 grams) diet; 2 liter fluid restriction _ Activity OOB with assistance Intake _N/A Output N/A Accu Cheks Vital signs. BP:126/72, Pulse:78/min, Tempt: 98.6F, Respiration:16/min, oxygen sat:98% on room air, Pain 0/10Drsg changes/wound care Foley N/A NG/G-tube/PEG?PEJ N/A IV right arm lower arm antecubital space Reason for IV normal saline 0.9%) 5MI IV Other orders: SCDs to bilateral lower extremities when not ambulating Titrate to keep O2 saturation above 92% weigh the patient every morning at the same time Most recent Imaging Findings: (CXR? CT? MRI?) Type of Imaging (X-Ray, CT, MRI, etc) Body Area Imaged Reason for testing and results of test x-ray AP Chest To view anatomy of lungs; Cardiomegaly and intestinal pulmonary edema Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?) Date Lab Test Results Norms Comments Lipid profile serum Cholesterol – 208 HDL- 45 LDL-115 Triglycerides- 129 Cholesterol – < 200 HDL- >45 LDL- < 100 Triglycerides- < 150 High levels of cholesterol, triglyceride, LDL; put at risk for heart dieases CBC All normal N/a Normal BMP All normal n/a Normal aPPT 30 secs 25-35 Normal PT 12 secs 11-15 Normal INR 1.1 0.8-1.1 Normal Magnesium, serum 1.9 1.3-2.1 Normal Phosphorus, serum 4.4 2.5-4.6 Normal BNP 5.1 <3.1 High BNP; more likely heart failure Other recent, significant procedures or tests (EKG, etc) Date Test Reason for testing and results of test 12 lead ECG To assess the electrical activity of the heart. Result pending TTE Ultrasound test of the heart. Result pending Based on the information on these pages and your assessment of this patient, what is your FIRST or PRIORITY concern and why? Decrease cardiac output - The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness, and paleness. Medications You may copy and paste these tables onto the next sheet if you have more medications Brand Name and Generic Name Normal Dosage Ranges Contraindications Furosemide / Lasix 20 – 80 mg Diabetes, a type of joint disorder due to excess uric acid in the blood called gout, low amount of electrolytes, hearing loss. Pharmacotherapeutic Class Dosage Ordered Adverse Reactions loop diuretics 40 mg nausea or vomiting, diarrhea. Constipation, stomach cramping. vertigo Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching to treat edema (fluid retention; excess fluid held in body tissues) IV x 1 now Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Brand Name and Generic Name Normal Dosage Ranges Contraindications Aspirin / Aspro Clear 50 mg to 6000 mg avoid also taking ibuprofen allergy to NSAIDs Pharmacotherapeutic Class Dosage Ordered Adverse Reactions NSAID 81 mg Hemorrhage, GI bleeding, GI upset, anorexia, Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching lower the risk of heart attack, clot-related PO daily Assess pain and/or pyrexia one hour before or strokes and other blood flow problems after medication. - In long-term therapy monitor renal and liver function and ototoxicity. Brand Name and Generic Name Normal Dosage Ranges Contraindications Enoxaparin / Lovenox 30-150 mg Administered concurrently with aspirin Pharmacotherapeutic Class Dosage Ordered Adverse Reactions Anticoagulants 40 mg Bleeding gums, coughing up blood. difficulty with breathing or swallowing, I ncreased menstrual flow or vaginal bleeding. Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching used to prevent and treat harmful blood clots. This helps to reduce the risk of a stroke or heart attack Subcutaneous daily contraindicated in pork hypersensitivity, monitor for signs of bleeding, administer in subcutaneous tissue. Medications Metoprolol tartrate / Lopressor blood sugar, depression. Pharmacotherapeutic Class Dosage Ordered Adverse Reactions beta blockers 25mg, fatigue, weakness, anxiety, nervousness Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching PO BID Ensure that patient swallows the ER Lowering high blood pressure helps tablets whole; do not cut, crush, or chew. prevent strokes, heart attacks, and kidney problems Brand Name and Generic Name Normal Dosage Ranges Contraindications Fish oil / Omega 3 fatty acids 200–4,000 mg slow blood clotting (Anticoagulant / Antiplatelet drugs) Pharmacotherapeutic Class Dosage Ordered Adverse Reactions Lipid-lowering agent 2400mg High Blood Sugar, Bleeding. Bleeding gums and nosebleed, Low Blood Pressure Why is patient receiving this med? (Can list related diagnosis, symptom, or need) Route and Frequency Nursing Considerations and Teaching PO daily Monitor for S&S of hypersensitivity in those decreasing the amount of triglycerides and with known allergy to fish. other fats made in the liver [Show More]

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