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Pointed Care Plan in Nursing

In: Science

Submitted By mabembe
Words 1141
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Anoka Ramsey Community College
Nursing 2482 Admitting Data Nursing Care Plan I Page 1 Room #: 1016 Patient Initials: ML Admit Date: 09/23/2010 Admitting Dx: Acute Congestive Heart Failure Age: 84 Sex: Female Marital Status: Married Surgery/Procedure: None Date of Surgery/Procedure: None POD/LOS (number): 6 Allergies: No known Drug Allergies Code Status: DNR

Significant Hx: History of nerve damage to her esophagus, HTN, history of venous insufficiency, psoriasis, encounter of palliative care, Acute Renal failure, acute myocardial infarction. Post Surgical History: Hx. of cholecystectomy. Patient has been married for 64 yrs and currently resides in an apartment with her husband.

Patient Story: She is an 84 yr old female who came to the ER on 9/23/10 complaining of SOB which she had been experiencing for approximately 4 days. She stated states she feels dyspnea both at rest and exertion. Feels better if she sits up. She has swelling on her legs, which she states is chronic and has been worse. Denies chest pain, but has had pain on her shoulder and back. She has a productive cough producing white phlegm. Appeared to be in CHF, admitted for evaluation. Lab tests done on 09/26/2010, CXR revealed that patient has CHF. She underwent a 2 D-ECHO which showed left ventricular cavity size at the upper limits of normal; moderately abnormal ventricular ejection fraction estimated at 35-40%. Patient started on IV Lasix. On 9/26/2010 hgb was 9.5, but it dropped to 7.8 on 9/27/2010, patient was infused with 2 units of PRBC’s. On the night of 9/27/10 patient experienced severe SOB after using the bathroom, RT was called and pt. was put on 3L of oxygen and a BIPAP was used. Pt. continues to have a non-productive cough. New medications ordered to decrease her fluid…...

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