NURS 101L - Nursing Care Plan .docx - 1 RUNNING HEAD...

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1 RUNNING HEAD: NURSING CARE PLAN Rose Ghassemi West Coast University NURS 101L-16
2 NURSING CARE PLAN Student Rose Ghassemi Date 03/08/2020 Instructor Professor Roselyn Barssoumian Course 101L-16 Patient Initial M.M. Unit/ Room# 208 DOB 68 Code Status Full Code Height/Weight Ht: 5’4” Wt: 245 lbs Allergies Penicillin Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O 2 Sat) Blood Pressure Pain Scale 1-10 97.8 F (Temporal) 98 (Radial) 24 87% on room air 165/88 mmHg 0/10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations 68-year-old female patient admitted to admitted to emergency room with severe shortness of breath, poor endurance, and lethargy. Patient states dyspnea is worse upon laying down and up exertion. Patient has a history of HTN, DM, CHF, PVD. Admission diagnosis: Hypervolemia due to CHF exacerbation Hypervolemia: Excess fluid volume. “Fluid overload is often viewed as primarily a phenomenon of the plasma space, but other fluid compartments may also be involved. The plasma and red blood cells together comprise a total blood volume of approximately 5 l. Both the extracellular space, occupying 15 l, and the intracellular volume of 25 l far exceed the intravascular compartment in size” (Kreimeier, 2000). Patient M.M. was brought to the emergency room by two daughters after experiencing severe dyspnea upon laying down at home. Patient states her dyspnea is worse upon lying down and upon exertion. She denies pain. Upon arrival her SpO2 was 87%, BNP 5988, BUN 32, and creatinine 1.9. Patient is obese, follows a sedentary lifestyle, eats foods mainly high in fat, fried and carbohydrates. She has a history of Hypertension, Diabetes Mellitus, Congestive Heart Failure, and Peripheral Vascular Disease. Two years ago she had her first cardiac stent placement. One year ago she had a second cardiac stent placement. Vital Signs : T: 97.8 F ( normal ) BP: 165/88 mmHg (abnormal)(HTN )(normal range: <120/<80)(Copstead & Banasik, 2013, p. 334). SpO2: 87% (abnormal) (normal range: ≥95%)(Copstead & Banasik, 2013, p. 495). Page 2 of 16
3 NURSING CARE PLAN CHF Exacerbation: CHF exacerbation is a clinical diagnosis based on at least 1 of the following symptoms: exertional dyspnea, fatigue, paroxysmal nocturnal dyspnea, orthopnea, cough, early satiety, weight gain, and increasing abdominal girth”(Feiz, 2015). Congestive Heart Failure: C ongestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure (hypertension), gradually leave your heart too weak or stiff to fill and pump efficiently (Mayoclinic, n.d.). Exacerbation: “ A relatively sudden increase in the severity of a disease or any of its signs and symptoms” (Copstead & Banasik, 2013, p. 1127).

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