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Oxygen 2 liter via NC in order to elevate and maintain the O2Sat. over 92% º In order to promote adequate oxygen to tissue and prevent necrosis of tissue/ organs 2. Initiate Cardiac Monitering º Since the potassium level is not within normal limits, and there are elevated levels of troponin in the blood, she is at risk for cardiac failure. 3. Examine daily weight 4. 1,500 Calorie and Cardiac Diet 5. Blood sugar checks before meals, 3 times a day, and before bedtime º S.E. has elevated glucose levels, and her glucose should be monitered in order to prevent hyperglycemia, as well and hypoglycemia. 6. Strict I&O monitering º Because of the high levels of BUN and Creatnine Serum, the kidneys may not be functioning properly. 7. SCD for DVT prophalaxis º Sequential Compression Device will be applied in order to prevent deep vein thrombosis. 8. Insert peripheral IV- 0.9% º Administered in order to try to elevate the blood pressure and blood volume. 9. Rocephin 2 gm IVPB q24 º An antibiotic to fight infection. Her WBC count is elevated which means she is fighting an infection. 10. ASA 81 mg PO qD º A low dose aspirin will be administered in order to reduce cardiac load in an attempt to prevent th heart from failing. 11. Docustate Sodium 100 mg PO BID PRN for constipation 12. Famotidine 20 mg PO Qd º a histamine-2 blocker, blocks the production of acid by acid- producing cells in the stomach
Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Page 8 of 13 13. Norco 5 mg/325mg 1 tablet q4h PRN º opiod administered for severe pain 14. Norco 7.5 mg/ 325 mg 1 tablet PO q4hrs PRN severe pain º opiod administered for severe pain 15. Dextromethorphan & Guaifenesin 10 mL q6hrs PRN for cough ºGuaifenesin is an expectorant. It helps loosen congestion in your chest and throat, making it easier to cough out through your mouth. 16. Albuterol 2.5 mg/ 3 mL via HHN q4hrs PRN SOB/Wheezing º Albuterol is a beta 2 agonist, which acts as a bronchiodialter 17. Tylenol 325 –2 tablets PO Q6HRS PRN º A sodium channel blocker, which acts by blocking sodium channels and prevents pain receptors from reaching the brain 18. Continue patient’s home medications Diagnostic Label Contributing Factors Signs and Symptoms Related to As evidenced by
Course: NURS 101L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L Page 9 of 13 Priority Nursing Diagnosis (at least 2) Written in three part statement Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based CitationsEvaluation Goal Met, Partially Met, or Not Met & Explanation Inadequate gas exchange related to congestion in the lungs as evidenced by a saturation of 87% RA, and verbalized chest pain of 4/10.