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COLLEGE OF NURSING
Student: Rachel Valchine
1 PATIENT INFORMATION
Patient Initials: WG
Age: 65
Gender: Male
I50.22 CHF
Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date:
Procedure:
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 65-year-old male who presented to the emergency department with complaints of chest pain and pressure that
began at 8:30 AM on day of admission. Patient described the pain as a constant pressure located on the left parasternal
area. The patient reported the chest pain was resolved after nitroglycerin was administered by EMS en route to the
Bayfront ED. The patient reported they had also been experiencing increasing shortness of breath over the past week. An
EKG, 2D echo, and chest x-ray were ordered and showed findings consistent with an acute exacerbation of the patients
CHF. The patient was admitted to 4 South and placed on a tele monitor for further evaluation.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation
Date
March 2013
March 2013
Father
Mother
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
(angina,
MI, DVT
etc.)
Heart
Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Environmental
Allergies
Cause
of
Death
(if
applicable
)
Stomach
CA
Alcoholism
2
FAMILY
MEDICAL
HISTORY
Operation or Illness
Acute MI
Angioplasty with stenting x 2
91
Brother
Sister
relationship
relationship
relationship
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date) U
Adult Tetanus (Date) U
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
YES
NO
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
NKA
Medications
NKA
Other (food, tape,
latex, dye, etc.)
5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Heart failure is a state in which the heart fails to pump blood at an adequate rate to meet the needs of the tissues it is perfusing
or it is able to do so only with an elevated diastolic blood pressure. Prior to heart failure, the body tries to compensate for the heart by
increasing the preload to help sustain heart function, altering myocyte death and regeneration, and myocardial hypertrophy.
According to Dumitru (2013) norepinephrine is released activating the renin-angiotension aldosterone system (RAAS) and the
sympathetic nervous system. This system acts to maintain arterial pressure and perfusion of vital organs. This activation of the RAAS
leads to salt and water retention by the kidneys which causes an increase in preload of the heart. This increase in preload then leads to
higher energy expenditure of the heart. The primary response to increased stress on the walls of the heart is myocyte hypertrophy,
death, and regeneration. This process subsequently leads to remodeling which only worsens the condition of the heart. This is an area
where many heart failure patients are treated. Medications are frequently used to lower the stress on the heart and slow the remodeling
process. Norepinephrine and epinephrine are also released, causing vasoconstriction and increasing calcium afterload. This causes an
increase in cytostolic calcium entry. The increased calcium entering the cells increases the contractility of the heart and reduces the
hearts ability to relax. The calcium overload can induce arrhythmias and lead to sudden cardiac death while the increase in cardiac
contractility and decrease in the ability to relax increases myocardial energy expenditure. The more energy the heart is using, the more
myocytes die. This causes heart failure and an even larger decrease in cardiac output (Dumitru, 2013).
Approaches to treating heart failure include nonpharmacological, pharmacological and more invasive strategies. If the heart
failure is not severe, nonpharmacological strategies are implemented such as monitoring dietary sodium and fluid intake, increasing
physical activity as appropriate, and paying attention to weight gains. Pharmacological therapies that may be used include the use of
diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, and digoxin. More invasive therapies include pacemakers,
ICDs, and CABG. In extreme cases where other therapies are not effective, a heart transplant may be used (Dumitru, 2013).
According to Heart Failure (2013), some risk factors for an increased preload include incompetent valves, renal failure, volume
overload, and a congentital right to left shunt in the heart. Some risk factors for increased afterload are hypertension, valvular stenosis,
and hypertrophic cardiomyopathy. Risk factors for decreased contractility include cardiomyopathy, coronary artery disease, acute
myocardial infarction, myocarditits, hypocalcelmia, and hypomagnesemia. Any or a combination of these factors can lead to heart
failure. Heart failure has genetic connections as well. It is a complex disorder that combines the actions of many genes with
environmental factors. Many of the risk factors that can lead to heart failure have a genetic predisposition including hypertension,
coronary artery disease, and myocardial infarction (Heart Failure, 2013).
Prognosis for heart failure patients is generally not good. Mortality following hospitalization is 10.4% at 30 days, 22% at 1 year
and 42.3% at 5 years. Each time a patient is rehospitalized, it increases their mortality by about 20%. For the best prognosis, patients
with heart failure should adhere to diet changes, exercise changes, and their medication regimen (Dumitru, 2013).
5 MEDICATIONs: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name: Carvedilol
Concentration (mg/ml)
Route: PO
Home
Hospital
or
Both
Concentration
Route: PO
Frequency: Daily
Home
Hospital
or
Both
Concentration:
Route: PO
Dosage Amount: 40 mg
Frequency: daily
Home
Hospital
or
Both
Concentration
Dosage Amount: 20 mg
Route: PO
Frequency: BID
Home
Hospital
or
Both
Concentration
Dosage Amount: 14 mg
Route: transdermal
Frequency: daily
Pharmaceutical class
Home
Hospital
or
Both
Concentration
Dosage Amount: 25 mg
Route: PO
Frequency: daily
Home
Hospital
or
Both
Concentration: 1 mg/0.25 mL
Route: IV Push
Dosage Amount: 1 mg
Home
Hospital
or
Both
Concentration
Route: SL
Frequency: PRN
Home
Hospital
or
Both
Concentration: 2 mg/ml
Route: IV Push
Home
Hospital
or
Both
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Cardiac
Analysis of home diet (Compare to My Plate and
Diet pt follows at home? Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
The patients intake of grains, vegetables, fruits, and dairy
is considerably less than the recommended daily amount.
Breakfast: 1 cup Cheerios cereal with 4 oz skim milk
Of particular concern for this patient is the excessive
amount of sodium present in his diet as this can cause fluid
Lunch: 2 pieces white bread, 4 Tbs peanut butter, 1 medium retention that can exacerbate CHF. Heart failure patients
banana, 1 small bag potato chips
are typically recommended to consume no more than 2,000
mg per day. The patients typical consumption was more
Dinner: 1 cup rice and beans, 1 chicken breast
than 2,300 mg. I would recommend that this patient avoid
packaged foods, replace salty snacks with fresh fruits and
Snacks: 1 cup buttered popcorn
vegetables, and consider using salt-free herb blends when
cooking to add flavor without the extra sodium.
Liquids (include alcohol): 16 fl oz coffee, 24 fl oz beer, 16
oz Coca Cola
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? My wife.
How do you generally cope with stress? or What do you do when you are upset?
Talking with my wife or family helps a lot
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient reports no recent feelings of depression/anxiety.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: According to McLeod (2008), generativity vs. stagnation occurs in middle adulthood. The objective of this stage
is to begin to establish careers, family, and become involved in the community. If these objectives are not achieved the result is
stagnation or a feeling of being unproductive (McLeod, 2008).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
I believe my patient is in the self absorption/stagnation stage. The patient stated they have been having difficulty staying
active within his church community (something that he used to do regularly), is currently unemployed, and has been
actively using illicit drugs. This suggests his development is somewhat stagnant at the moment.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
I think my patients disease process has had a profound impact on their development. It is possible that his drug usage and
unemployment could be related to the stress of his disease.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
My body just isnt what it used to be. Ive been dealing with this for a long time.
What does your illness mean to you?
It seems to be a never-ending challenge.
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active? Yes.
Do you prefer women, men or both genders? Women.
Are you aware of ever having a sexually transmitted infection? No.
Have you or a partner ever had an abnormal pap smear? No.
Have you or your partner received the Gardasil (HPV) vaccination? No.
Are you currently sexually active? Yes. When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? None.
How long have you been with your current partner? 33 years.
Have any medical or surgical conditions changed your ability to have sexual activity? No.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No.
Pack Years: 24
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? beer
How much? (give specific volume)
2 beers/day (24 fl oz)
thru
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
No.
10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: daily
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:
Gastrointestinal
Immunologic
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination:
Bladder or kidney infections
7x /day
Hematologic/Oncologic
Metabolic/Endocrine
x/day
x/year
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 2/3/14
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? 2/3/14
Other:
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
Integumentary:
HEENT:
Pulmonary: Patient admitted with difficulty breathing but has since resolved. Patient is currently on 2L nasal
cannula and was able to ambulate on the floor without significant drop in O2 saturation. Last CXR on 2/3/14
showing cardiomegaly with pulmonary vascular congestion.
Cardiovascular: Patient diagnosed with hyperlipidemia and hypertension currently well controlled with
medication. Last EKG on 2/3/14 showing a normal sinus rhythm with no acute changes. Patients recent
admission is likely due to an exacerbation of his CHF.
GI:
GU:
Women/Men Only: Patient reports he has an annual prostate exam, the last one was in July of 2013 with no
abnormal findings.
Musculoskeletal:
Immunologic:
Hematologic/Oncologic:
Metabolic/Endocrine:
Central Nervous System:
Mental Illness:
Childhood Diseases:
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No.
Any other questions or comments that your patient would like you to know?
No.
10
talkative
withdrawn
quiet
boisterous
aggressive
hostile
Location: LH
Location: RFA
Location:
flat
loud
Date inserted:
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 4 / 4 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6 inches & left ear- 6 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: overall good dentition, no missing or damaged teeth.
Comments:
11
Pulmonary/Thorax:
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: midclavicular 5 th ICS
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
No JVD
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: straw yellow
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 2 / 4 /14)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
&
5 in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps: 2+
Biceps: 2+
Brachioradial: 2+
Patellar: 2+
Achilles: 2+
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
BNP
1,736 pg/mL (HIGH)
1,069 pg/mL (HIGH)
Dates
2/3/14
2/4/14
CK MB
9.0 (CRITICAL)
11.6 (CRITICAL)
8.6 (CRITICAL)
2/3/14, 10:50
2/3/14, 16:42
2/3/14, 23:30
Troponin
0.03 g/L
0.04 g/L
0.04 g/L
2/3/14, 10:50
2/3/14, 16:42
2/3/14, 23:30
Trend
Upon admit, the patients
BNP was elevated to
1,736. The next draw on
2/4/14 showed a reduced
level at 1,069.
Patients labs showed an
increase and then
decrease in CKMB levels
while within the hospital
setting.
Echocardiogram
2/3/14
Drug Screen
2/3/14
Analysis
BNP levels above 900
pg/mL indicative of
severe heart failure.
CKMB levels indicated
damage to myocardial
muscle. They can be
detected within 3 to 8
hours of the onset of chest
pain, peak within 12 to 24
hours, and usually return
to baseline levels within
24 to 48 hours.
The presence of low
troponin levels indicates
there was previous
damage to the heart
muscle. The low levels
and stability of these
levels over time suggests
the patient is likely not
currently experiencing an
MI.
Depressed left ventricular
function indicating
weakening of the heart
muscle. Indicative of
dilated ischemic
cardiomyopathy.
Cocaine usage is
EKG
2/3/14
Non-specific ST changes.
No evidence of acute
change. No other EKGs
were performed for
comparison.
CXR
2/3/14
CXR showed
cardiomegaly with
pulmonary vascular
congestion.
commonly associated
with many heart problems
such as heart failure, heart
attack, and dilated
cardiomyopathy.
Patients PMH is
significant for an acute
MI in March of 2013.
EKG results are likely a
result of this past cardiac
event.
Enlargement of the heart
does not allow blood to
pump effectively,
resulting in heart failure.
15 CARE PLAN
Nursing Diagnosis: Decreased cardiac output r/t altered contractility aeb decreased ejection fraction
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day care is
Goal
Provide References
Provided
1. Sinus tachycardia and increased arterial
blood pressure are seen in the early stages;
BP drops as the condition deteriorates.
2. Cold, clammy skin is secondary to
compensatory increase in sympathetic
nervous system stimulation and low
cardiac output and desaturation.
3. Pulses are weak with reduced cardiac
output
4. Compromised regulatory mechanisms
may result in fluid and sodium retention.
Body weight is a more sensitive indicator
of fluid or sodium retention than intake
and output.
5. Crackles reflect accumulation of fluid
Patient will remain free of side effects
secondary to impaired left ventricular
from the medications used to achieve
emptying. They are more evident in the
adequate cardiac output through hospital
dependent areas of the lung.
discharge.
6. Physical activity increases the demands
placed on the heart; fatigue and exertional
dyspnea are common problems with low
cardiac output states. Close monitoring of
patient's response serves as a guide for
optimal progression of activity.
7. Indicates an imbalance between oxygen
supply and demand.
8. Adherence to medication regimen helps
to control symptoms, keep vitals within
normal limits, and prevent further
exacerbation of CHF.
2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
X F/U appts
X Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Patient will demonstrate adequate cardiac
output aeb blood pressure, pulse rate and
rhythm within normal parameters for the
client.
1. Assess HR and BP
2. Assess skin color and temperature
3. Assess peripheral pulses
4. Assess fluid balance and weight gain.
5. Assess lung sounds.
6. Assess response to increased activity
7. Assess for chest pain
8. Administer medication as prescribed,
noting response and watching for side
effects and toxicity. Clarify with physician
parameters for withholding medications.
Rehab/ HH
Palliative Care
15 CARE PLAN
Nursing Diagnosis: Impaired gas exchange r/t excessive fluid in interstitial space of lungs
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Interventions on
Goal
Provide References
Day care is Provided
1. A study by Hagle (2008) demonstrated
1. Patient maintained normal respiratory
Patient will demonstrate improved 1. Monitor respiratory rate, depth, and
ease of respiration. Watch for use of
that when the respiratory rate exceeds 30
rate and ease of respiration.
ventilation and adequate
accessory muscles and nasal flaring.
breaths/min, along with other
2. Bread sounds were clear but diminished
oxygenation.
2. Auscultate breath sounds every 1 to 2
physiological measures, a significant
in all lobes. No adventitiuous breath
Patient Goals/Outcomes
References
Ackley, B. & Ladwig, G. (2014). Nursing diagnosis handbook : an evidence-based guide to planning care. Maryland Heights, Missouri: Mosby
Elsevier.
Dumitru, I. (2013, October 1). Heart Failure-Pathophysiology. Retrieved from Medscape: http://emedicine.medscape.com/article/163062overview#aw2aab6b2b3
Heart Failure. (2013, October 8). Retrieved from Nursing Central : http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-andDisorders/73601/all/Heart_Failure
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis: Elsevier.
McLeod, S. A. (2008). Erik Erikson | Psychosocial Stages - Simply Psychology. Retrieved from:
http://www.simplypsychology.org/Erik-Erikson.html