NURSING PLAN

Nursing Plan

Nursing Care Plan



STUDENT

Patrice Gutt

CLIENT'S INITALS

J.D.

DIAGNOSIS

Impaired Cardiac Output

Nursing Diagnosis:

PRIIORITY PROBLEM 1 Impaired Cardiac Output

PRIORITY PROBLEM 2 Risk for infection

PRIORITY PROBLEM 3 Ineffective breathing

PRIORITY PROBLEM #1 Behavioral Outcomes (formulate to be accomplished on date of care)

[1] No Auscultations should be there in Patient's lungs

[2] No signs of dyspnea should be there

PRIORITY PROBLEM #1 Overall Goal (upon discharge improvement/resolution of nursing diagnosis will be evidenced by)

Patient will demonstrate an increase in activity intolerance

Nursing Interventions -PRIORITY PROBLEM #1

Scientific Rationale for Intervention

1 Skin color, moisture, temperature, and capillary refill time should be observed

1 Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output.

2 Note dependent/general edema.

2 May indicate heart failure, renal or vascular impairment.

3 Administer Lasix 20 mg

3 Assess RR, SP02, Listen to lungs decrease crackles

4 Administer Digoxin 0.125 mg

4 Monitor HR, decrease in BP

5 Monitor rate of IV drugs closely, using infusion pumps, as appropriate,

5 To prevent bolus/overdose

6 Evaluate client reports and evidence of extreme fatigue, intolerance for activity, sudden or progressive weight gain.

6 To assess for signs of poor ventricular function.

Evaluation of Behavioral Outcome

[1] Patient shall have participated in activities that reduce the workload of the heart.

[2] Display hemodynamic stability (e.g., blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses).

Evaluation of Overall Goal

Verbalize knowledge of the disease process, individual risk factors, and treatment plan.

PRIORITY PROBLEM #2 Overall Goal (upon discharge improvement/resolution of nursing diagnosis will be evidenced by)

Patient will be saved from the any side effects of the medications used

Nursing Interventions -PRIORITY PROBLEM #2

Scientific Rationale for Intervention

1 Monitor the patient for any infection or side effects caused by the medications being administered

1 Presence of temperature, digestive system issues, or sleep disturbances may be due to the side effects or infections created by the administered medications..

2 Administer WBC 12,000, Ancef 1 g IV Q8H, T 99.6

2 Would help in preventing side effects

3 Insert Foley Catheter

3 Would help in preventing side effects

Evaluation of Behavioral Outcome

[1] No side effects or infections should have shown

[2] Patient should display improvement in his stability conditions.

Evaluation of Overall Goal

Validate the absence of side effects at the end of hospitalized period.

PRIORITY PROBLEM #3 Overall Goal (upon discharge improvement/resolution of nursing diagnosis will be evidenced by)

Patient will be saved from the any side effects of the medications used

Nursing Interventions -PRIORITY PROBLEM #3

Scientific Rationale for Intervention

1 Listen to lungs decrease crackles

1 May Depict breathing issues

2 Administer Sp02 94% on 2L/min oxygen, RR 22

2 Listen to lungs decrease crackles

3 Administer Lasix 20 mg. DX of CHF

3 To resolve breathing issues

Evaluation of Behavioral Outcome

[1] Patient shall have participated in breathing exercises

Evaluation of Overall Goal

The issues of ineffective breathing must have eliminated, if any.

Jlanier/2012

Concept Care Map

Student

PATRICE GUTT

Patient's Occupation

N/A

Diet

CLEAR FLUIDS

Client's Initals, Age, Gender

J.D. 70 FEMALE

Culture

N/A

Allergies

NKA

Date of Admission

Religion

N/A

Med/Surg History

CHF, A.FIB, DIABETES, ORIF



Date Relationships

STUDENT

Patrice Gutt

CLIENT'S INITIALS

JD

DIAGNOSIS

Impaired Cardiac Output

Problems

A

B

Impaired cardiac output relates to infection

A

C

Impaired cardiac output relates to Risk of Ineffective Breathing

A

D

Impaired cardiac output relates to Risk of Dehydration

A

E

Impaired cardiac output relates to Issues in Physical Mobility

A

F

Impaired cardiac output ...