Care Arrange for Chf
NURSING CARE PLAN SAMPLE DATABASE Mr. Jose Rodriguez, an 84-year-old client, was admitted to the hospital about 6/20/02 with shortness of breath. This kind of retired Asian grower, a widower, declares that within the past 3- weeks he has received increasing -4 fatigue and shortness of breath. This individual visited his doctor 2 days ago, great medication was increased. His preferred meals are fresh fruits and vegetables, grain, red coffee beans and tortillas. Mr. Rodriguez lives with one of his daughters and her friends and family since suffering from a myocardial infarction 23 years ago. He has six different children. He's a Catholic and attends church on a regular basis; however , seeing that his decreasing health, he has been limited to his residence. He is visited at home every week by his church porquerizo and/or representative. He speaks with take great pride in about his grocery store that he started for his family. He smoked two packs per day times 40 years and quit in 1990. Mister. Rodriguez was admitted which has a diagnosis of long-term congestive cardiovascular failure (CHF) with serious exacerbation. His medical history comes with coronary artery disease x 10 years. He had a go up angioplasty in 2000 and an Meters. I. 23 years ago. He is experiencing impaired and wears zwischenstaatlich hearing aids. He wears eyeglasses and reads without difficulty. This is his third admission for CHF seeing that his diagnosis five years ago. Physician improvement notes coming from 6/22/02 state: Condition enhancing; c/o lessening SOB; chest x-ray increasing; serum K+ is three or more. 3, and weight decreased 8# in past 8 weeks. Admitting history and Physical test 6- -02 -20Moderate respiratory distress; crackles auscultated in left lung base Currently sleeping about 3 pillows at night to help ease breathing. Nocturia X4 this past week. Mild heart murmur; no JVD, peripheral pulses +2; COMPARED TO: 98. 6- -28, 176/94, Ht. 5'7вЂќ, Wt. 154#, Baseline BP 145/90 -88c/o increasing tiredness and serious shortness of breath (SOB) O2 LAY level -- 90% in room atmosphere. Denies heart problems. 6- -02 -206- -02 -206- -02 -206- -02 -206- -02 -206/22/02 6/20/02 Digoxin zero. 25 mg po QD Lasix 40 mg po bid Nitro-Bid 2 . five mg po qid Metamucil 15 cubic centimeters po q hs in glass of water/juice KCl 20 mEq po put money Chest x-ray-mild left ventricular hypertrophy; pulmonary congestion managing. Serum electrolytes: Na+ 138 mEq/L K+ 3. three or more mEq/L Ca+ 9. 1 mg/dl CL- 102 mEq/L Serum ?ggehvidestof 2 . almost 8 g/dl Serum digoxin level 2 . six ng/dl Bun 30 mg/dl Cr zero. 6 mg/dl
Diagnostic tests results
6/20/02 6/20/02 6/20/02 Other acknowledging orders
No added salt diet; I & To, daily wts, activity since tolerated BRP with aid, VS Queen 4 hours T-MOBILE at 3L/min per sinus cannula Heparin lock States " my own old center is just wearing out. I get this extra smooth every now and then. We come here for the hospital to reduce it. вЂќ Seems well oriented and it is a progressive historian; effectively reported medications he had recently been on in the home. c/o congestion. Skin reddened over bony prominences. At present requires HOB elevated to help ease breathing. Requires W/C to get transport. Needs ADL help. Gait unsteady. Family by bedside. -- -1NSGCAREPLAN(Sample): you: 1/06
Medical Interview & Observations
TEST NURSING CARE PLAN RIVERSIDE COMMUNITY SCHOOL DATE BREASTFEEDING EDUCATION STUDENT________________________________ SEMESTER INSTRUCTOR____________________________ ROTATION Client's Initials J. R. Male or female M Age 84 Code Status Full Admission Date 6- -02 -20-
Showing Signs/Symptoms (What brought the customer to the hospital? ) Elevating fatigue and SOB times 3- several weeks -4 Admitting/Primary Diagnosis Long-term CHF with acute excitement Surgeries Associated with this Entry None
Extra Diagnoses (Diagnoses other than admitting diagnosis that impact this admission. ) CAD (coronary artery disease). S/P MI (1988) Great Present Disease (What led up to this hospitalization? ) Client started to be more SOB and exhausted 3- several weeks ago. Lasix was improved to forty five mgs qd on 6/18/02. Presented to -4 Elizabeth. R. with в†‘ SOB and dyspnea. Previous Surgical Procedure(s) as well as Date(s) As well as the Angioplasty (1 vessel) 2150 Health History (Include amount of time client...
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