ADH2 Care Plan 2 copy.docx - Nursing Care Plan Student Darren Hunnicutt Client\u2019s Initials M.K Allergies NKDA Activity Up as tolerated Diet Cardiac

ADH2 Care Plan 2 copy.docx - Nursing Care Plan Student...

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Nursing Care Plan Student: Darren Hunnicutt Dates of care: 1/22/2014 Client’s Initials: M.K. # 33 Age: 79 Sex: M Admit date : 1/21/14 Allergies: NKDA Activity: Up as tolerated Documented Code Status: Full Code Advance Directives: Noted in chart Diet: Cardiac Diet with 1.2 liter/day fluid restriction Recommended Diet for this Disease Process: Cardiac Diet: Cardiac diet is meant to prevent and/or treat cardiovascular disease. The 3 main goals of the cardiac diet: 1. Lower blood cholesterol levels 2. Lower blood pressure 3. Reduce body weight. Educate patient on the DASH diet. The DASH diet helps lower blood pressure. The diet includes lots of fruits, vegetables, low-fat dietary foods, and foods that are low in saturated fat, total fat, and cholesterol. Using the DASH diet with a low salt diet may help lower blood pressure. Primary Medical Diagnosis: Congestive Heart Failure Other Related/Underlying Medical Problems/Diagnoses: HTN, GERD, Tonsillectomy, Left leg surgery Surgical or Invasive Procedures and Dates if this admission: Echocardiogram 1/21/14 Heart Catheterization 1/21/14 Chronological summary of events during hospitalization: Client M.K. was admitted through the emergency department at SVMC on 1/21/14. Client presented to the E.D. with mid-sternal chest pain and shortness of breath. PT verbalized to E.D. nurse that he has noticed a 10lb weight gain over the last week. After multiple tests, the client was newly diagnosed with congestive heart failure. PT currently awaiting cardiology consults for open heart surgery d/t 3-vessel disease.
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Explanation of Diagnosis, Surgery, and/or Procedure Congestive Heart Failure: Inability of the heart to circulate blood effectively enough to meet the body’s metabolic needs. Heart failure may affect the left ventricle, right ventricle, or both. It may result from impaired ejection of blood from the heart during systole or from impaired relaxation of the heart during diastole. Signs & symptoms: Right sided heart failure- dependent edema, abd. distention, anorexia, nausea, increased b/p. Left sided heart failure- dyspnea, tachypnea, crackles in lungs, pulmonary congestion. (Silvestri, 2010) (Perry, Potter & Elkin, 2011) Hypertension - Condition in which the blood pressure is higher than 140 mm Hg systolic or 90 mm Hg diastolic. Signs & symptoms: may be asymptomatic, headache, visual disturbances, chest pain , and tinnitus. (Silvestri, 2010) (Perry, Potter & Elkin, 2011) MEDICATIONS Medication Generic / Trade Safe Dose Range/ Ordered Dose Route, T ime, Frequency If IV, include dilution & rate Classification, Action, & Indication for Client Major Side Effects Nursing Implication Generic: Aspirin Trade: ASA Safe Dose: 50-325mg once daily Ordered: 81mg daily 81mg Tab PO QD given @ 9am C- antipyretic, non opioid analgesics A- Prophylaxis of transient ischemic attacks and MI.
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