NURSING CARE PLAN SAMPLE DATABASE Mr.

Jose Rodriguez, an 84--year--old client, w

as admitted to the hospital on 6/20/02 with shortness of breath. This retired Hi
spanic grower, a widower, states that for the past 3--4 weeks he has had increas
ing fatigue and shortness of breath. He visited his doctor two days ago, and his
medication was increased. His preferred foods are fresh fruits and vegetables,
rice, red beans and tortillas. Mr. Rodriguez lives with one of his daughters and
her family since experiencing a myocardial infarction in 1988. He has six other
children.
He is a Catholic and attends church regularly; however, since his declining heal
th, he has been confined to his home. He is visited at home weekly by his church
pastor and/or representative. He speaks with pride about his grocery store that
he started for his family. He smoked two packs per day x 40 years and quit in 1
990.
Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure
(CHF) with acute exacerbation. His medical history includes coronary artery dise
ase x 10 years. He had a balloon angioplasty in 2000 and an M.I. in 1988. He is
hearing impaired and wears bilateral hearing aids. He wears glasses and reads wi
thout difficulty. This is his third admission for CHF since his diagnosis five y
ears ago. Physician progress notes from 6/22/02 state: Condition improving; c/o
decreasing SOB; chest x--ray improving; serum K+ is 3.3, and weight decreased 8#
in past two months.
Admitting history and Moderate respiratory distress; crackles auscultated in lef
t lung base Physical exam Currently sleeping on 3 pillows at night to ease breat
hing. 6--20--02 Nocturia X4 this past week.
Mild heart murmur; no JVD, peripheral pulses +2;
VS: 98.6--88--28, 176/94, Ht. 5â 7â , Wt. 154#, Baseline BP 145/90
c/o increasing fatigue and severe shortness of breath (SOB)
O2 SAT level -- 90% on room air. Denies chest pain.
Medications ordered 6--20--02 Digoxin 0.25 mg po QD
6--20--02 Lasix 40 mg po bid
6--20--02 Nitro--Bid 2.5 mg po qid
6--20--02 Metamucil 15 ml po q hs in glass of water/juice
6--20--02 KCl 20 mEq po bid
Diagnostic tests results 6/22/02 Chest x--ray--mild left ventricular hypertrophy
; pulmonary congestion resolving. 6/20/02 Serum electrolytes: Na+ 138 mEq/L K+ 3
.3mEq/L Ca+ 9.1 mg/dl CL-- 102 mEq/L 6/20/02 Serum albumin 2.8 g/dl 6/20/02 Seru
m digoxin level 2.6 ng/dl 6/20/02 Bun 30 mg/dl Cr 0.6 mg/dl Other admitting orde
rs No added salt diet; I & O, daily wts, activity as tolerated
BRP with assist, VS Q 4 hours
O2 at 3L/min per nasal cannula
Heparin lock
Nursing Interview & States â my old heart is just wearing out. I get this extra flu
id every now Observations and then. I come here to the hospital to get rid of it
.â Seems well oriented and is a fluent historian; accurately reported meds he had
been on at home. c/o constipation. Skin reddened over bony prominences. Currentl
y
requires HOB elevated to ease breathing. Requires W/C for transport. Needs ADL a
ssist. Gait unsteady. Family at bedside. -- 2 -- NSGCARE PLAN(Sample):2:1/06 SA
MPLE NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATION STUDEN
T________________________________ SEMESTER INSTRUCTOR___________________________
_ ROTATION Clientâ sInitials J.R. Gender M Age 84 Code Status Full AdmissionDate 6-
-20--02 Presenting Signs/Symptoms (What brought the client to the hospital?) Inc
reasing fatigue and SOB x 3--4 weeks Admitting/Primary Diagnosis Chronic CHF wit
h acute exacerbation Surgeries Related to this Admission None Secondary Diagnose
s (Diagnoses other than admitting diagnosis that impact this admission.) CAD (co
ronary artery disease). S/P MI (1988) History of Present Illness (What led up to
this hospitalization?)
Client became more SOB and tired 3--4 weeks ago. Lasix was increased to 40 mgs q
d on 6/18/02. Presented to
E.R. withâ SOB and dyspnea.
Previous Surgical Procedure(s) / Date(s) Balloon Angioplasty (1 vessel) 2000 Hea
lth History (Include length of time client has had disease processes; significan
t family history; social issues.) CAD x 10 years. CHF x 5 years. MI 1988. Substa
nce Use (Include use of tobacco, alcohol, street drugs, over--the--counter drugs
, length of use and time of last use.) 2 PPD x 40 years. Quit 1990. Denies ETOH,
drug use. Allergies/Reactions NKA ReligiousPreference Catholic Ethnicity Hispan
ic MaritalStatus W Occupation Retired Pathophysiology/Current Health Problems an
d Related Functional Changes: Define each primary and secondary diagnosis and ex
plain the disease process of each. Also include signs and symptoms, risk factors
, treatment options, possible complications, and functional changes that affect
activities of daily living (ADLs).
Source: Smeltzer and Bare, 2000 CHF: Congestive heart failure (CHF) often referr
ed to as cardiac failure, is the inability of the heart to pump sufficient blood
to meet the needs of the tissues for oxygen and nutrients. As with coronary art
ery disease, incidence increases with age. Common underlying conditions that lea
d to decreased myocardial contractility include myocardial dysfunction (especial
ly from coronary atherosclerosis), arterial hypertension and valvular dysfunctio
n (p. 622). Functional changes relate to inadequate tissue perfusion, dizziness,
confusion, fatigue, exercise or heat intolerance, cool extremities, oliguria, s
odium and fluid retention. Increased pulmonary venous pressure leads to cough, S
OB and pulmonary edema. Increased systemic venous pressure may result in general
ized edema and weight gain (p. 665).
CAD: The most common heart disease in the U.S. is atherosclerosis, which is an a
bnormal accumulation of lipid, or fatty substances and fibrous tissue in the ves
sel wall. These substances create blockages or narrow the vessel in a way that r
educes blood flow to the myocardium (p. 594). Functional changes depend on the d
egree of narrowing. Angina pectoris is recurrent chest pain that is brought on b
y physical exertion or emotional stress and relieved by rest or medication (p. 5
95).