Paciente ingresado en uci tras fallo cardiaco seguido de cada.

Se le
administra medicacin prescrita por el medico (suelen ser enalapril,
valsartan, bisoprolol, furosemida y digoxina). Una vez estabilizado el
paciente de su diagnostico principal se proceder a realizar un plan de
cuidados enfermeros que incluir objetivos y acciones.
Los objetivos son:
Efectividad bomba cardaca: controlaramos presion arterial,
frecuencia cardaca, pulso, coloracin de la piel, arritmias, posible
edema pulmonar y disnea.
Cognicin: el paciente debido a su demencia no se comunica de
forma clara ni se encuentra orientado, tampoco toma decisiones
apropiadas.
Conducta de prevencin de cadas: para evitar posibles cadas se
colocarn barreras para prevenirlas, barandillas, ayuda personal y
eliminacin de objetos.
Las acciones que realizaremos para llevar a cabo estos objetivos sern:
Cuidados cardacos: evaluar el dolor torcico, comprobar la
circulacin perifrica, realizar electrocardiograma y monitorizar.
Se har anlisis para evaluar enzimas cardacas y electrolitos y se
controlar el equilibrio de lquidos. Se administrar la medicacin
pertinente y observar la respuesta del paciente.
Estimulacin cognoscitiva: En cuanto a la memoria se estimular
hacindole repetir los ltimos pensamientos expresados por .l

paciente, orientndolo en espacio y tiempo, reforzando y repitiendo

informacin. Utilizar la medicacin prescrita por el medico
Prevencin de cadas: controlaremos marcha, equilibrio

deambulacin, ayudndole y animndole. colocar todos los

objetos cerca del paciente y le recordaremos que para cualquier
movimiento pida ayuda. El personal se encargar de moverlo.
Patient admitted to the intensive care unit after Congestive Cardiac
failure followed by a fall. Prescribed medication will be given by the
doctor (usually enalapril / captopril, valsartan, bisoprolol, furosemide
and digoxin). Once the patients primary diagnosis is stabilized, a plan
of care nurses will proceed ncludind goals and actions.
The goals are:
Effectiveness heart pump: we will control blood pressure, heart
rate, pulse, skin coloring, arrhythmia, possible pulmonary edema
and shortness of breath.
Cognition: due to patients dementia, he cant communicate clearly
nor oriented, he does neither take appropriate decisions.
Conduct of prevention of falls: to avoid possible falls there will be
barriers to prevent them as railings, personal assistance and
deleted objects.
The actions that we have to take to carry out these goals will be:

Cardiac care: I will assess chest pain; check his peripheral

circulation; effect electrocardiogram and monitories him. There will
be analysis to assess patients cardiac enzymes and electrolytes

and balance of liquids will be also monitoriesed. Proper medication

will be administered and patients response will be observed.
Cognitive stimulation: Taking into account the memory, the patient
will be stimulated by repeatedly asking his last expressed thoughts,
trying to orientate him in space and time, reinforcing and repeating
information. I will use prescribed medication prescribed by the
doctor
Preventing Falls: Balance and ambulation will be checked, helping
and encouraging the patient. I will put all the objects close to the
patient and the patient will be remembered that for any movement
he should ask for help. The staff will be on charge in case the
patient needs to be moved