Ara Manalang

NURS360
Professor Michelle Marineau

Evaluation
In order to measure if the patient has sufficient cardiac output, it is important for the nurse to assess
capillary refill, oxygen sat, and must note and report any respiratory distress (use of accessory muscle, increased
respiratory rate, report of being dyspneic and SOB) to HCP. It is also important to review pertinent labs (e.g.
ejection fraction). The desired outcome was partially met. I was able to do the nursing assessments to determine
the cardiac output.
Oxygenation is one of the most important things that a nurse must look into during a patient assessment.
Respiratory rate & effort must be assessed. Elevated RR may indicate that patient is having a hard time breathing
which results in the patient having to breathe faster. Oxygen sat must be greater than 95% in room air. Desired
outcome was partially met, the patients O2 sat went lower than 95% at some point, but the patient was
asymptomatic.
Since the patient has CHF, she is automatically placed at risk for developing FVE. Signs and symptoms of
FVE that a nurse must watch out for include full, bounding pulse, jugular vein distention, weight gain of more than
3lbs a day, possibly crackles on the lungs. As a nurse, we also need to review pertinent labs like the BNP level,
which becomes elevated with patients who have FVE. BNP level increases as a result of heart muscle being
stretched.
Since the patient has decreased cardiac output, it would affect the circulation and perfusion which leads
to the patient being on bed rest. By being on bed rest, there are 2 things that the patient is at risk for. First one will
be developing DVT. Assessment of BLE is a must, noting s/sx of DVT (inflammation, cramping pain usually in calf,
pain, warmth feeling of the skin on the surrounding areas upon palpation). Another risk from being on bed rest
would be constipation. Its the nurses duty to assess any sign and symptoms of patient being constipated (noting
the last time patient made BM, what color and consistency, bowel sounds, palpation of abdomen). Desired
outcomes were met, and patient did not suffer from DVT. Patient had a regular bowel movement without any
complaints of being constipated.
Altered nutrition is also an important aspect to consider. Patient complains of lacking appetite, patients
BMI is lower than average. Assessment includes taking patient weight every day, checking patients food intake.
Reviewing patients pertinent lab values such as RBC count. Pain is considered the 6th vital sign, it is a must to
assess pain often. Pain is a subjective thing that only patient can describe. As a nurse, I use the numeric pain rating
scale to assess my patients pain because it is the appropriate pain rating tool for my patients age.

Discharge Plan/Patient Teaching

Patient will be discharged back home. Her support system will be her husband, who is a pediatrician. Patient is
independent with most ADLs. However, patient will need someone to assist her for the first 2 weeks after being
discharged at home to monitor for possible orthostatic hypotension. Patient will need a two-wheel walker as an
assistive device. Patient teaching was made (medications, signs and symptoms to watch out for, etc.) educated the
patient about the importance of checking the blood pressure and heart rate before taking COREG and AVAPRO.
Because of decreased EF, patient was made aware that she should expect low blood pressure. Educated patient
about dangling on the edge of the bed before getting up to avoid orthostatic hypotension. Patient to keep heart
healthy diet (low sodium, low cholesterol). Fluid intake is also restricted to prevent FVE. Encouraged patient to
take the hospital cup with measurement home in order for her to keep track of her fluid intake. Patient verbalized
understanding about the teaching and also verbalized that she will follow up with her PCP as scheduled. Informed
the patient that if she experiences any difficulty of breathing, she must call 911 immediately.