PATIENT CARE PLAN STUDENT PATIENT INITIALS ADMITTING DX R.B AGE 82 Abdominal pain, difficulty breathing, pleural effussion NURSING DIAGNOSIS (in priority order) DATE Short term: pt will reduced symptoms of decreased cardiac output within by discharge Subjective: pt has stated that “I have an abnormal heart rhythm my doctor said it was called a-fib" Long term: pt will come up with a plan to help increase physical activity over the next month. OTHER MEDICAL DX Atrial Fibrillation, High blood pressure, hyperlipidemia, stroke, hypothyroidism April 21,2021 PATIENT-CENTERED GOALS Nursing Diagnosis: Decreased cardiac output r/t alteration in heart rhythm Objective: BP: 128/112 Weight: 88.64 Age: 82 T: 97.5 Pulse:110 SaO2:97% RR: 16 CXR: bilateral infiltrates CT: trace fluid low pelvis and bilateral pleural effusion Sex:male NURSING INTERVENTION RATIONALE Reassessment: BP: 80/ 71 T: 97.4, SaO2: 97% pulse: 90, RR: 12 Independent 1. Nurse will recognize and report symptoms of reduced cardiac output such as tachycardia, rales, and irregular heartbeat each day. 1. Knowing signs and symptoms can help determine if pt is having reduced cardiac output or experiencing heart failure (Ackley et.al. 2017, pg 188) 2. Nurse will position pt in semi or high fowler position and elevate lower extremities after daily assessment. 2. 3. 3. Nurse will promote a relaxing environment with reduced stressors by end of day 4. 4. Nurse will check BP, pulse, and pt condition before administering ordered medications 1. Pt has signs decreased cardiac output such as crackers in lungs, tachycardia, and thready pulse and treatment for these symptoms has started. April 20,2021 Elevating head of bead and lower extremities may decrease work of breathing and promote venous return. (Ackley et.al. 2017, pg 188) 2. Pt has expressed having an easier time breathing after positioning in semi fowler’s position after he stated, “it feels much easier to breath now.” April 20,2021 Promoting a stress-free environment reduces cardiac workload and oxygen demand Ackley et.al. 2017, pg 188) 3. Pt was able to identify factors in the environment that were a source if stress and was able to come up with activities that help him relax. April 21,2021 4. Pt was feeling very fatigued after being administered heart medications. Doctor was informed of pts reaction. April 21, 2021 It is important to know how pt is tolerating cardiac medications before giving them (Ackley et.al 2017, pg 189) Dependent 1. 1. Nurse will work with doctor and pt, and pt EVALUATION Cardiac rehab can improve quality of life for a heart failure family members about referring pt to cardiac rehab program for education and monitored exercise before discharge. pt and regular exercise is recommended for heart failure pts (Ackley et.al 2017, pg 190) 5. Pt has expressed interest in cardiac rehab and in implementing physical activity into treatment plan. April 22,2021 STG: still pending as pt is still undergoing care and has not been indicated for discharge yet. Will be reassessed when pt is indicated for discharge. April 22,2021 LTG: still pending, pt will be reassessed after discharge and upon follow-up. April 22,2021