NRSG 201 Good Care Plan Example-11
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Grand Canyon University *
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NRSG201
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Medicine
Date
Dec 6, 2023
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Ivy Tech Community College
NRSG 201 Med Surg III – Care Plan Packet
Student Name
Clinical Date
S
ituaton
Patient’s
Age Range
Code Status
Admission
Date
Other gender
explanation/remove if
NA
Partial code
explanation/remove
if NA
Allergies
Pineapple- mouth swelling, Penicillin- hives, Sulfa drugs- diarrhea
Primary Medical Diagnosis:
Acute on chronic diastolic heart failure
Pathophysiology of Medical
Diagnosis:
Diastolic heart failure occurs when the heart has lowered cardiac output due to thickening of the left ventricular wall.
This thickening causes the left ventricle to be stiff and make the left ventricular cavity much smaller.
This causes an
increase of resistance for the left ventricle to fill during diastole leading to the lower-than-normal cardiac output
(Cheever 2018).
Etiology of Medical
Diagnosis:
Diastolic heart failure is most often caused by uncontrolled chronic hypertension that causes the large arteries in the
body to stiffen and the left ventricle to hypertrophy.
Other conditions can lead to left ventricular hypertrophy such as
ischemia and uncontrolled diabetes (Cheever 2018).
Most common
complications:
According to the textbook, diastolic heart failure displays the following complications most commonly: dyspnea at
rest and during exertion, orthopnea, productive cough, weight gain, and low oxygen saturation (Cheever 2018).
Usual Treatment
Modalities:
According to the textbook, diastolic heart failure is treated by improving quality of life and managing the patient’s
symptoms.
This is accomplished through lifestyle changes such as daily weight monitoring, diet that is low in salt,
and a fluid restriction that can be anywhere from 1 to 2 liters per day.
Supplemental oxygen can be used if the client
is having difficulty keeping their oxygen saturation up.
Blood pressure medications are used to control hypertension
and reduce the afterload of the heart.
Beta-blockers can also be used to decrease the afterload and control the
patient’s heart rate.
Diuretics such as furosemide are used to help the patient get rid of excess fluid that they might
be holding.
Lastly, digoxin can be used to improve the hearts contractibility (Cheever 2018).
Comparison of this patient
to the textbook
information:
My patient was very similar to what was described in the textbook.
He was showing signs of dyspnea, edema,
activity intolerance, productive cough and orthopnea.
His treatment plan was also very much like the textbook
described, he was on a cardiac diet, 1500 ml fluid restriction, supplemental O2, diuretics, and beta blockers.
Background
Pre-hospital (outpatient)
and ER Care
While at home my patient had been experiencing increased shortness of breath and weight gain for a few days.
He
called the doctor’s office on Friday 10/7 to ask what he should do due to his symptoms, and they told him to double
the morning torsemide dose, which he did.
Doubling his dose for the morning did not seem to solve the symptoms
so he ended up calling EMS that same day to take him to the ED.
On the way to the ED he was given albuterol to help
relieve his shortness of breath, which did give some temporary relief.
While in the ED he was assessed and had a
chest x-ray that relieved some pulmonary edema.
He then had an IV Lasix drip started and was sent to the PCU.
Past Medical History
Chronic heart failure, arteriosclerotic heart disease, Gerd, Edema, Pleural effusion, A-fib, Hypertension, Type 2
Diabetes mellitus, anxiety, depression, anemia, COPD, Coronary artery disease.
Surgical History
Appendectomy, CABG x3, Cardiac Catheterization, C-Section, Thoracentesis.
No surgeries during current stay.
A
ssessment
Vital Signs
MORNING
8:00
AFTERNOON
11:00
Temp
98.5
Temp
98.5
Pulse
85
Pulse
100
RR
18
RR
18
BP
147/69
BP
146/67
O
2
Sat
94%
2 L
O
2
Sat
99
2L
Pain
Pain
Head-to-toe
Assessment
Findings
Neuro
Patient A&O x4.
PERRL at 3mm. Glasgow Coma Scale of 15.
Swallowing and Chewing WNL, MM are moist,
pink and intact. Pt missing some teeth. Pt able to follow commands as needed. Pt facial features are
symmetrical.
Musculo-
skeletal
Pt grips are equal 5/5 bilaterally and lower extremity strength is equal bilaterally 5/5 Patient
ambulates without assistance
Respiratory
Pt is on 2L O2 via NC.
Respirations are labored after activity. Anterior and Posterior lungs sound
clear/diminished bilaterally. Pt has productive cough w/ small amount of white/thick sputum
Cardiac
S1 and S2 audible. HR 85, irregular rhythm w/ A-fib. Pt on continuous telemetry. Apical and radial
pules correlate.
Radial pulses +2 bilaterally, Pedal pulses +2 bilaterally. Cap refill <3 on fingers and
toes bilaterally. +1 pitting edema on ankles bilaterally.
GI
BS normoactive x4 quadrants. Last BM before hospital on 10/7 hard brown stool. Abdomen round,
soft, and obese. Pt on low fat cardiac diet w/ 3-4g salt restriction and 1500 mL fluid restriction.
GU
Continent, voiding clear yellow urine w/ no pain.
Skin
Skin is warm, dry, intact, and appropriate for ethnicity. Lower legs are dry and flaky bilaterally. No
skin tears or punctures.
Pt is currently in the chair w/ the alarm on.
Psychosocial
Pt began day in good mood and cooperative, later became frustrated w/ his situation. Pt is appropriate
to the situation. Pt family appropriate and helpful.
Spiritual/
Cultural
Pt has met w/ the chaplain regarding frustration and feelings of loss of control. Pt wants to continue living to
spend time with his children and grandchildren.
EENT
Pt is not hard of hearing. Pt has vision impairment in both eyes, wears glasses to correct. Pt missing
teeth but no dentures.
Focused
Assessment
1)
Respiratory system because he has had frequent bouts of dyspnea and pulmonary congestion.
2)
Cardiovascular to monitor heart sounds and the swelling in ankles to determine if he is holding more fluid.
3)
Neurological to ensure he is still oriented and that a CVA is not occurring due to A-fib rhythm.
Isolation
Reason for Isolation
No contagious diseases
2
Tubes/Drains
N/A
Diet Order
Cardiac diet, Low fat, 3-4g NA, 1500mL fluid
Amount consumed
Breakfast
Lunch
IV Assessment
IV
Site
Right AC
Gauge/
Lumen
IV Site
Assessment
☒
Clean
☒
Dry
☒
Patent
☐
Redness
☐
Tenderness
☐
Hardened
☐
Painful
☐
Streaking
Additional IV
Site/ IV Site
Notes
None
IV Fluids
None
IV Fluid Rate
N/A
Activity Orders
Activity as tolerated
Nursing Activity
Precautions
N/A
Shift Activity
Walked to and from the bathroom three times.
Sat up
in chair for meals. Completed assessment with
physical therapist.
Hygiene
Care
Helped apply lotion to his skin because it was dry.
Patient
did not need assistance with bathing, patient completed a
CHG bath and oral care.
Call Orders
Heart rate <60 or >120, Respiratory Rate <12 or >25, Temperature >100.6, Urine Output <30 ml/hr, Systolic Bp <90 or >180, Diastolic Bp <60 or
>90, MAP < 65
MEDICATIONS
Medication Name
Dose
Route
Frequency
Why is the patient taking the prescribed
medication? What is the medications
mechanism of action?
Apixaban
5mg
Oral
2x Daily
Pt is taking to prevent the formation of clots due to
A-Fib.
The medicine prevents clotting by inhibiting
clotting factor Xa (Lippincott 2022).
Diltiazem
120mg
Oral
2x Daily
Pt is taking to control hypertension. The medicine
reduces the amount of calcium ions that can flow
into the heart during depolarization (Lippincott
2022).
Guaifenesin
600mg
Oral
2x Daily
Pt is taking to reduce congestion in chest and to help
cough up the mucus. The medicine thins secretions
in the lungs to help cough them up (Lippincott
2022).
Metoprolol
50mg
Oral
Daily
Pt is taking to reduce tachycardia and help keep
blood pressure under control. This medicine blocks
beta1-receptors to reduce heart rate and blood
pressure (Lippincott 2022).
3
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Torsemide
20mg
Oral
Daily
Pt is taking to increase urination to get rid of excess
fluid that he is retaining. This med is a loop diuretic,
so it prevents Na and Cl from reabsorbing in the
loop of Henle (Lippincott 2022).
Ipratropium
2.5mg
Nebulizer
As needed
Pt is taking to help open airways to improve
breathing during bouts of shortness of breath. This
medicine is an anticholinergic, so it blocks
acetylcholine from attaching to muscarinic
cholinergic receptors (Lippincott 2022).
Add more rows by pressing the “tab” button on the keyboard while in this box.
SAFETY
1)
He began the day as a moderate fall risk, so we had a fall risk band on him and used the chair alarm.
2)
Allergy to pineapple, penicillin, and sulfa so we had an allergy band on him
3)
Used proper patient identifiers to avoid medication errors.
PERTINENT LABS
(based on the patient’s diagnosis, history, medications, etc., which labs are pertinent and why?)
Lab Name
Normal
Range
Patient Results
Reason Abnormal
(specific to this patient)
Why would the provider order
this test?
High, Low or
Normal?
High, Low or
Normal?
High, Low or
Normal?
WBC
3.2-11
9.6
14.4
9.5
Doctor believed there was some
pneumonia due to the pulmonary
congestion.
RBC
3.6-5.4
3.35
3.35
3.77
Pt has a history of anemia.
HGB
11.6-15.2
8
8
9
Pt has a history of anemia.
HCT
34.4-45.6
28.1
28.9
32.1
Pt was experiencing fluid volume
excess due to heart failure
reducing HCT levels.
CO2
22-30
35
36
29
CO2 increased due to ineffective
breathing patterns.
Creatinine
0.52-1.04
1.21
1.41
1.33
Creatinine was high due to the
fluid overload and kidneys not
being able to filter it properly.
Glucose
65-99
382
359
278
Pt has a history of uncontrolled
4
DM type 2.
BNP
<300
6000
Patient’s
Result
Patient’s
Result
Pt had congestive heart failure.
Abnormal due to fluid overload
and stretch on the heart.
Patient’s
Result
Patient’s
Result
Patient’s
Result
Add more rows by pressing the “tab” button on the keyboard
while in this box.
Pertnent Diagnostcs
Other Diagnostics
Results
Reason Abnormal
Chest X-Ray 8/3/25
X-Ray showed signs of pleural effusion.
This happened because the Pt has diastolic heart
failure, and it can cause fluid to back up into the
lungs.
Chest X-Ray 8/5/25
X-Ray showed signs of improvement of the
pleural effusion.
The diuretics and fluid restriction were working to
remove the excess fluid in the lungs.
Summary Course of Stay
On 8/3 the patient was having worsening shortness of breath and weight gain from fluid retention.
He decided to call EMS to have him brought
to the hospital.
On the way to the hospital, he received albuterol to help with his breathing.
Once at the ED he was assessed and taken to a
chest x-ray where signs of pleural effusion were found.
He was started on a Lasix drip and admitted onto the PCU.
While in the PCU he was put
on a 1500ml fluid restriction, cardiac diet with 3-4g of sodium restriction.
He also resumed his medicine that he was taking at home including
metoprolol, diltiazem, and Eliquis.
During his stay he discussed with the doctors that Lasix does not work for him and prefers to use torsemide.
He was later put on the oral torsemide instead of Lasix.
On 8/5 he had another chest x-ray and it showed signs that the pleural effusion was
improving due to the diuretics and restrictions.
On 8/5 he continues to improve with less shortness of breath and edema.
We continued to
educate him on why it is essential he sticks to the fluid and diet restrictions to help prevent him from returning to the hospital.
In the afternoon
he had a physical therapy assessment to determine his activity tolerance and dependence on O2 where he did well and was able to maintain at
least 92% oxygen while moving around the room and did not show any signs of balance issues. Patient also wants to discuss home health
opportunities to help him monitor vitals and to check in on him.
The nurse believes he will be going home within the next few days if his
condition continues to improve, and he remains compliant.
Based on the patient’s
abnormal lab values or diagnostc studies
, what Nursing Assessments/ Interventions need to be implemented to
prevent harm or further decline in Patient condition?
Frequent assessments of respiratory and cardiovascular systems need to be done.
Strict I/O monitoring of fluid and diet.
Continue to educate
on lifestyle changes and medication compliance.
5
Recommendaton
CLINICAL DECSISION MAKING
RECOGNIZE and ANALYZE CUES:
Based on the abnormal findings (cues) that you have found cluster the findings that are related to each other.
(
For
example, patient c/o pain 8/10 and has an elevated B/P.)
Sob with movement and at rest- oxygen dependence- pleural effusions- pitting edema -heart failure-BNP 6000
Feelings of fear and frustration with chronic illness and feelings of loss
Knowledge deficit- too much fluid- was on a high salt and unlimited fluids at home- not compliant with meds- not having daily weights at home
Diabetes high blood sugars- poor diet choices candy at bedside
Fall risk- taking diuretics frequent toileting- on oxygen
CO2 high- SOB and oxygen requirement -pleural eff
HYPOTHESIS:
Based on your cluster of cues, list actual and potential problems your patient has under the nursing concept.
Nursing Plan for Care
Neurological/Cognition/Behavior
:
Actual:
Knowledge deficiency of CHF, DM and Diet
Safety
:
Actual: Fall risk
Potential: Polypharmacy
Oxygenation/Gas Exchange/Perfusion
:
Actual: Altered breathing pattern, Altered tissue perfusion,
Pain/Comfort
Potential: Pain
Infection/Immunity/Inflammation
:
Potential: Infection risk
Mobility/Self-Care
:
Actual: Bathing/hygiene ADL deficit assist of 1, Activity intolerance,
Deconditioning
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Tissue Integrity
:
Potential: Altered skin integrity risk
Sensory Perception/Communication:
Knowledge deficiency medication questions
Nutrition:
Potential: Electrolyte imbalance
Health Promotion/Education
:
Actual: Altered health maintenance
Elimination
:
Actual: Toileting ADL deficit
Potential: Bowel and Urinary Incontinence
Cultural/Spiritual/Psychosocial:
Actual: Psychosocial/spiritual needs- feelings of hopelessness and frustration,
Death anxiety
Fluid/Electrolytes/Acid-Base
:
Actual: Fluid overload
Potential: Electrolyte imbalance
Coping/Adaption
:
Potential: Coping impairment chronic illness
Metabolism/Glucose Regulation
:
Potential: Hyperglycemia risk, Hypoglycemia risk
Other
:
Potential: Caregiver fatigue
Prioritize Hypotheses
Priority Nursing Problem:
Impaired gas exchange
GENERATE SOLUTIONS
Patient will maintain an oxygen saturation level of at least 92% for the remainder of hospital stay.
TAKE ACTION
(MUST INCLUDE 3 ACTIONS)
1)
Assess patients O2 saturation levels.
Apply oxygen to patient via nasal cannula.Supplemental oxygen increases the
percentage of oxygen that is inhaled with each breath which increases the amount that is absorbed into the blood
(Cheever 2018).
RATIONALE
:
Frequently measuring the patient’s O2 saturation levels will show if the patient’s lungs are perfusing properly
(Cheever 2018).
2)
Sit patient up in chair and/or bed
RATIONALE
Positioning the patient upright helps to promote chest and lung expansion which then helps the lungs to perfuse
7
:
oxygen (Cheever 2018).
3)
Apply oxygen to patient via nasal cannula.
RATIONALE
:
Supplemental oxygen increases the percentage of oxygen that is inhaled with each breath which increases the amount that is
absorbed into the blood (Cheever 2018).
EVALUATE OUTCOMES
Goal partially met. Patient was able to maintain an oxygen saturation level of 92% during the shift.
This level was maintained
during rest and activity with and without the supplemental oxygen.
Continue plan and reassess each shift before he is discharged.
Second Priority Nursing Problem:
Excess fluid volume
GENERATE SOLUTIONS
The patient will demonstrate a return to baseline weight by end of admission.
TAKE ACTION
(MUST INCLUDE 3 ACTIONS)
1)
Enter Monitor and measure the patient's fluid intake and output.
RATIONALE
:
This ensures that the patient is not taking in too much fluid and that the patient is voiding enough fluid during the day to get rid of
the excess (Cheever 2018).
2)
Nurse will weigh the patient daily
RATIONALE
:
Daily weights are the most effective way to monitor if a patient is holding excess fluid (Cheever 2018).
3)
Limit the patient's fluids, as ordered; educate the patient and family (as appropriate) about the importance
of following fluid restrictions
RATIONALE
:
Body has too much fluid and is not excreting fluid properly so limiting fluids will reduce fluid over load. (Cheever 2018).
This ensures that the patient is not taking in too much fluid and that the patient is voiding enough fluid during the day to get rid of the excess
(Cheever 2018).
EVALUATE OUTCOMES
Goal not met. Patient displayed signs of edema in both of ankles throughout the day. Continue plan and reassess each shift.
Third Priority Nursing Problem:
Alerted tissue perfusion
GENERATE SOLUTIONS
The patient will demonstrate no further worsening of tissue perfusion by having a heart rate between 60-90
by end of
shift
TAKE ACTION
(MUST INCLUDE 3 ACTIONS)
1)
Enter Assessment/Intervention
Auscultate apical pulse to assess heart rate
8
RATIONALE
:
Tachycardia is one of the body’s mechanisms to increase cardiac output and persistent tachycardia can be a sign that the heart is
failing and can be harmful to the body (Cheever 2018).
2)
Encourage the patient to rest and help with care when needed.
RATIONALE
:
This should reduce the demand placed on the patient’s heart, so their heart does not have to work as hard (Cheever 2018).
3)
Therapeutic communication and provide a quiet environment
RATIONALE
:
Helping the patient to avoid stressors can help to lower their heart rate and blood pressure (Cheever 2018).
EVALUATE OUTCOMES
Goal partially met.
The patient was able to keep the heart rate under 100 bpm but the blood pressure had bouts of hypertension
throughout the day.
Continue plan and reassess each shift
Fourth Priority Nursing Problem:
Knowledge deficit related to lack of understanding about heart failure and how it is related to other body systems
GENERATE SOLUTIONS
The patient will demonstrate knowledge retention related to heart failure by end of shift.
TAKE ACTION
(MUST INCLUDE 3 ACTIONS)
1)
Educate the patient on the importance of maintaining a fluid restriction while at home.
RATIONALE
:
Fluid restrictions can help to prevent recurrence of fluid volume excess.
While also reducing the cardiac workload of the heart
(Cheever 2018).
2)
Educate the patient on maintaining a cardiac diet with a salt restriction.
RATIONALE
:
Excessive sodium can cause the body to retain more fluid and to offset the effect of diuretics.
This can lead to the body retaining
too much fluid (Cheever 2018).
3)
Educate the client on medications and what they are used for.
RATIONALE
:
Understanding the medications and why the patient is using them can help to improve compliance (Cheever 2018).
EVALUATE OUTCOMES
Goal met.
Patient verbalized to me that he understood what he needed to do to help prevent further heart failure episodes.
Continue plan and assess each shift to further improve education and compliance.
PATIENT TEACHING
9
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1)
Educated the patient on how sitting up can help with breathing and lung expansion for when he feels like he is having shortness
of breath.
2)
Educated the patient on following a strict fluid restriction even when at home.
I explained to how the excess fluid causes the
weight gain and the shortness of breath.
3)
Educated the patient on following a sodium restriction and what types of foods are high in salt.
I told him how he is more likely
to retain fluid when eating more salt and to avoid processed foods as much as possible due to the high sodium content.
4)
Educated the patient on all medications and their actions on heart failure.
References (in APA format)
Cheever, J.L.H.K. H. (2018).
Lippincott CoursePoint Enhanced for Brunner & Suddarth's Textbook of Medical-Surgical Nursing
(14th ed.). Wolters
Kluwer Health.
https://coursepoint.vitalsource.com/books/9781975123383
Lippincott. (2022). Advisor for Education. Retrieved October 11, 2022, from https://advisor-edu.lww.com/
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