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FLORIDA INTERNATIONAL UNIVERSITY

COLLEGE OF HEALTH AND URBAN AFFAIRS


SCHOOL OF NURSING
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME
DATE
Client Initials
R.J.
Unit
Room/Bed
4PAV
416
Age
Sex
35
M
Weight
Height
139 kg, 308 lb
85.40 cm
Current medical diagnosis
Severe Cardiomyopathy

Culture/Ethnicity
African-American
Religion
Christian, non-denominational
Language
English
Marital status
Divorced
Occupation
Unemployed
Health insurance
N/A

Current work status


Unemployed
Highest grade completed
Some High School
Diagnostic procedures:
Labs to be taken and analyzed:
Chest XR (single view).
Oxygen routine once daily until D/C.
BMP timed, CBC and DIFF timed,
Standard EKG.
total CK, CK/MB, and Troponin I
Complete Echo Doppler
timed, ABGs, sodium, potassium,

Surgical procedures:
N/A

Support system
Mother; lives with.

Children: x3
2 daughters, 1 son
Name of significant other/primary caregiver
Primary Care Giver:
Mother: S.J..
Daughter: M.J., K.J..
Son: T.J.
Genogram: Use back of page

Patient Care Orders:


Vital signs post cardiac catheter.
I/O every shift.
Notify doctor if bleeding present.
Bedrest- 6 hrs routine.

chloride, glucose (random), BUN,


creatinine, myoglobin, PT-INR, PTT,
hepatic function panel, amylase,
lipase, and urinalysis.
Past Surgical History:
Past Medical History:
N/A
See Below

Pathophysiology: (List reference)

Psychopathology:

Newly diagnosed patients with


Dilated Cardiomyopathies are
characterized by progressive cardiac
cardiomyopathy may feel more stress,
hypertrophy and dilation and subsequently, anxiety, fatigue, anger, depression or
impaired pumping ability of one or both
sadness, and guilt. They may withdraw from
ventricles. Thromboemboli are a potential
loved ones and some daily activities and
risk due to the presence of mural thrombi
have fewer everyday pleasures to enjoy.
and there is also evidence of myocardial
cells that are scarred and atrophic. Dilated Similarly, a patients loved ones may also
experience distress when the patient has
Cardiomyopathy may result from any
condition or injury that ensues damage to
pain or life-threatening manifestations and
the myocardium, such as chronic
symptoms of this disease.. A combined
hypertension, alcohol, inflammation i.e
psychological approach to disease
myocarditis, and immunologic disorders.
management with emphasis on
Genetic influences have been noted in
psychosocial support is key to the
many cases, yet alcohol consumption
continues to be the most preventative and improvement and prolongation of quality of
life. Psychological treatments can be
second leading cause of a dilated
cardiomyopathy. Initial symptoms are similar effective in reducing anxiety, depression,
to those of heart failure and include an
and pain and help patients have a better
extreme decrease in the left ventricular
quality of life. As part of psychological
ejection fraction, ventricular arrhythmias,
support, the goal of treatment is to strive to
exertive dyspnea, paroxysmal nocturnal
help patients develop better ways of coping
dyspnea, weakness, ascites, peripheral
with the diagnosis and pain and develop
edema and enlarged apical beat with
presence of a third and fourth heart beat,
motivation to exert lifestyle changes that will
and murmur. Treatment is aimed at
help prevent symptom exacerbations.
reducing the workload of the heart involving (Marshall, 2002). My patient currently is
such medications as digoxin, diuretics, ACE
expressing sever anxiety and uncertainty
inhibitors, aldosterone antagonists, and Bover his new diagnosis.
Blocker drugs.(Porth, 2007).

BRIEF HEALTH HISTORY


SUMMARY:
Vital signs/Frequency
The patient was admitted to the hospital on 03/02/11 with severe cardiomyopathy
manifested by dyspnea, palpitations, heart murmur, S4 gallop and BP 160/116. A CT 03/03/11 1500
scan and other diagnostic measures such a cardiac catheterization demonstrated
profound myocardial hypertrophy and dilation. The patient was monitored postBP:
149/112 mmHg
procedure for possible bleeding and hematoma formation, and contrast agent-induced Temp: 97.0 Fahrenheit
nephropathy by observing elevations in serum creatinine levels. Other nursing
HR:
92 Beats per min.
interventions involved maintaining client bedrest and assessing for any dysrhythmias Resp: 20 Breaths per min.
due to a vasovagal reaction via distended bladder or discomfort from pressure applied SpO2: 99% (2L NC)
during removal of catheter or arterial insufficiency evidenced by affected extremity
pain, numbness, or tingling sensations.
03/03/11 1100
PAST MEDICAL HISTORY:
BP:
156/113 mmHg
Congestive heart failure, hypercholesterolemia, hypertension, heart palpitations, gout, Temp: 96.4 Fahrenheit
chronic snoring, and tobacco use (17 pack/year).
HR:
88 Beats per min.
Resp: 20 Breaths per min.
PAST SURGICAL HISTORY:
SpO2: 100% (2L NC)
N/A
Assess if any change in health status occurs.
____________________________________
ALLERGIES:
Allergies/Side effects
No allergies to any medication.
NKDA
____________________________________
MEDICATIONS:
Diet with rationale:
Takes a diuretic and various NSAIDS and OTC medications at home.
Low Cholesterol, Low Fat Diet
PHYSICAL EXAMINATION:
General:
He is obese, tall and oriented x3
Vital Signs:
He is afebrile. BP is elevated with no signifcant changes in RR, HR, or
Temperature.
Neck:
Supple.
Chest:
Clear of adventitious sounds. Mitral Murmor and S4 gallop heard upon
auscultation, as well as irregular heart beats (skipped).
Abdomen:
Distended- ascites, central obesity.
IMPRESSION AND PLAN:
The patient presents with a medical diagnosis of severe cardiomyopathy. Patient is
being monitored post- cardiac catheterization and discharge teaching will involve
discussion of pharmacological regimen, non-medical therapeutic lifestyle changes

This client presents with a history of high


cholesterol and blood pressure. Three dietary
elements affect cholesterol and its lipoprotein
fractions: (1) excess calories, (2) saturated
fats, and (3) cholesterol. By decreasing dietary
intake of these elements, in addition to other
lifestyle modifications such as exercise, the
client should experience a therapeutic weight
reduction and a decreased risk of
atherosclerotic events and complications
(Porth, 2007).
___________________________________
Activity order:

such as decrease in cholesterol, saturated fats, and purines in diet and use of a life
vest Holter monitor at home.

Bed rest for 6 hours routine following cardiac


catheterization. Ambulate out of bed with
assistance; patient instructed to ambulate 3-5
times a day with assistance after bedrest order
is discontinued.. Fall prevention interventions
initiated; call light within clients reach; bed
placed at lowest position; side rails up X2.
____________________________________
Limitations/prosthetic devices
Physical activity may be limited due to fatigue
associated with decreased ventricular pumping
ability and resulting dyspnea.
A life vest Holter monitor will be instituted
upon discharge. This device is a tape-recorder
like machine that the patient wears and that
continuously records the ECG on tape, which
is later viewed and analyzed with a scanner. It
is useful for observing occasional cardiac
arrythmias, or epilectic events that would be
difficult to identify in a shorter period of time.
The clients are encouraged to resume daily
activities as normal since its purpose is to
record how a heart works under various actual
conditions over an extended period of time
(Smeltzer, 2010).

PERTINENT LABORATORY
DATA Lab Test #1

PERTINENT LABORATORY
DATA Lab Test #2

Albumin

PERTINENT LABORATORY
DATA Lab Test #3

PERTINENT LABORATORY
DATA Lab Test #4

Total Protein

White Blood Cells


Sodium
(WBC)
(Na)
__________________________ ___________________________ ___________________________ ___________________________
Results:
2.2 g/dL [below normal]

Results:
4.1 g/dL

Reference Range:
3.5-5.0 g/dL

Reference Range:
6.0-8.5 g/dl

[below normal]

Results:
13.1 /mcl [above normal]

Results:
134 mmol/L

Reference Range:
3.8-9.8 /mcl fl

Reference Range:
135 147 mmol/L

[below normal]

___________________________ ___________________________ ___________________________ ___________________________


Rationale of abnormal results
Rationale of abnormal results
Rationale of abnormal results
Rationale of abnormal results
Decreased levels may be due to
Lower levels are seen in poor
poor nutrition, liver disease,
diets, diarrhea, fever, infection,
malabsorption, diarrhea, or
liver disease, inadequate iron
severe burns. Increased levels
intake, third-degree burns and
are seen in lupus, liver disease,
edemas or hypocalcemia. May be
chronic infections, alcoholism,
decreased due to fluid shift
leukemia, and tuberculosis
(Porth, 2007).
amongst many others (Smeltzer,
2009).

The WBC is really a


Hyponatremia occurs in CHF,
nonparameter, since it simply
severe burns, hypothyroidism,
represents the sum of the counts severe nephritis, Addison's, fluid
of granulocytes, lymphocytes,
loss: vomiting, diarrhea,
and monocytes per unit volume of sweating, malabsorption
whole blood. Automated counters syndrome, edema, too much IV
do not distinguish bands from
infusion or water by mouth,
segs; however, it has been
diuretics, stomach suctioning,
shown that if all other
pyloric obstruction, Diabetic
hematologic parameters are
acidosis (Smeltzer, 2009).
within normal limits, such a
distinction is rarely important.
Also, even in the best hands,
trying to reliably distinguish bands
from segs under the microscope
is fraught with reproducibility
problems. Discussion concerning
a patient's band count probably
carries no more scientific weight
than a medieval theological
argument. (Smeltzer, 2009).

PERTINENT LABORATORY
DATA Lab Test #5

PERTINENT LABORATORY
DATA Lab Test #6

Chloride
Neutrophils
(Cl)
__________________________ __________________________
Results:
85.2 % [above normal]

Results:
95 mmol/L %

Reference Range:
54-62 %

Reference Range:
96 106 mmol/L

[below normal]

___________________________ ___________________________
Rationale of abnormal results
Rationale of abnormal results
Neutrophils are the main
defender of the body against
infection and antigens. High
levels may indicate an active
infection (Porth, 2007).

Causes of hypochloremia include


severe vomiting, Respiratory
acidosis, Diabetes, gastric
secretion, burns, metabolic
alkalosis, overhydration,
Addisons, select diuretic
treatment (Porth, 2007).

INTRAVENOUS SOLUTION #1
Type: IV infusion
[21ga IV access to RAC]
D5W NaCl 0.9%: 1000 mL Q24H PRN daily.
Rationale for solution: often used to restore fluid and electrolyte
imbalance. Pertinent to the maintenance of homeostasis.

MEDICATION NAME

DOSAGE
ORDERED

TIMES
DOSE
ADMINISTERED ROUTE

RATIONALE FOR
ADMINISTERING

TRADE/GENERIC
Zestril (lisinopril)

40 mg tab

Q24H daily

PO

Alone or with other


agents in the
management of
Hypertension;
management of
heart failure;
reduction of risk of
death or
development of HF
after MI. (Davis
Drug Guide, 2010)

Coreg (carvedilol)

6.25 mg tab Twice daily

PO

Atropine

0.5- 1mg

PRN daily

IV push

THERAPEUTIC NURSING IMPLICATIONS


RANGE FOR
AGE/WEIGHT
Adults: 10mg
once daily, can
Monitor BP and pulse frequently
be increased up
during initial dosage adjustment
to 20-40 mg/day.
and periodically during therapy.
Initiate therapy at For heart failure, monitor weight
5 mg/day in
and assess for fluid overload.
patients recieving Correct volume depletion, if
diuretics. (Davis
possible, before initiation of
Drug Guide,
therapy.
2010)
May cause fatigue, dizziness, or
headache.
(Davis Drug Guide, 2010)

Decreased heart
rate and blood
pressure. Improved
CO, slowing of the
progression of CHF
and decreased risk
of death. (Davis
Drug Guide, 2010)

For hypertension,
6.25 mg twice

daily, may be
increased every
7-14 days up to
25 mg twice
daily. (Davis
Drug Guide,

2010)

Antidote for
bradycardiaincreases heart
rate. Reversal of
muscarinic effects,
decreased GI and

IV (adults0: 0.5-
1mg; may repeat
as needed q 5
min, not to
exceed a total of
2 mg. (Davis

Monitor BP and pulse frequently


during dose adjustment period
and periodically during therapy.
Monitor I/O ratios and daily
weight. Routinely assess for
evidence of fluid overload.
May cause bradycardia,
exacerbation of CHF symptoms,
and pulmonary edema.
(Davis Drug Guide, 2010)
Intense flushing of the face and
trunk may occur 15-20min
following IM administration and is
not harmful.
Y-site incompatible with
thiopental.

respiratory
Drug Guide,
secretions. (Davis 2010)
Drug Guide, 2010)

If overdose occurs,
physostigmine is the antidote.
(Davis Drug Guide, 2010)

Lasix (furosemide)

20 mg tab

Twice daily

PO

Diuresis and
subsequent
mobilization of
excess fluid
(edema, pleural
effusions) (Davis
Drug Guide, 2010).

For edema: PO
(adults): 20-80
mg/day as a
single dose
initially, may
repeat in 6-8 hr;
may increase
dose by 20-40

mg every 6-8 hr
until desired
response. (Davis
Drug Guide,
2010)

Assess fluid status. Monitor daily


weight, I/O ratios, amount and
location of edema, lund sounds,
skin turgor and mucous
membranes.
Monitor BP and pulse before and
after administration.
Patients taking digoxin are at risk
for digoxin toxicity because of
potassium- sparing effect (Davis
Drug Guide, 2010).

Ecotrin (Aspirin)

81 mg tab

Q24H daily

PO

Analgesia,
reduction of
inflammation and
fever, decreased
incidents of
transient ischemic
attacks and MI
(Davis Drug Guide,
2010).

Prevention of

ischemic attacks:
50-325 mg daily.
Prevention of MI:
80-325 mg daily
(Davis Drug
Guide, 2010).

Patients who have asthma,


allergies, and nasal polyps, or
who are allergic to tartrazine are
at an increased risk for
developing hypersensitivity
reactions.
Assess pain before and after
administration.
Monitor labs for symptoms of
hepatotoxicity. (Davis Drug
Guide, 2010)

Increased survival
in patients with
severe HF. Weak
diuretic and
antihypertensive
response when
compared with
other diuretics.
(Davis Drug Guide,
201

PO (Adults): 25-
400 mg/day as a
single dose or 2
divided doses.
For CHF: 25-50
mg/day (Davis
Drug Guide,
2010).

Aldactone
(spironolactone)

25 mg tab

Q24H daily

PO

Monitor intake and output ratios


and daily weight during therapy.
Monitor response of signs and
symptoms of hypokalemia or for
development of hyperkalemia.
Caution patient to avoid salt
substitutes and foods that contain
high levels of potassium.
Avoid if breastfeeding. (Davis
Drug Guide, 2010)

Norvasc (amlodipine 5 mg tab

Q24H daily

PO

Systemic
vasodilation
resulting in
decreased BP;
coronary
vasodilation
resulting in
decreased
frequency and
severity of attacks
of angina (Davis
Drug Guide, 2010).

PO (Adults): 5
10 mg daily. If
hepatic
impairment,
initiate therapy at
2.5 mg/day and
increase as
tolerated up to 10
mg day (Davis

Drug Guide,
2010).

NURSING DIAGNOSES

Monitor BP and pulse before


therapy, and after. Monitor ECG
periodically during prolonged
therapy.
Assess for signs of CHF
(peripheral edema,
rales/crackles, dyspnea, weight
gain, jugular venous distension)
Dose reduction recommended in
geriatric patients due to risk of
hypotension.
Contraindicated in a systolic BP
< 90 mm Hg (Davis Drug Guide,
2010).

NURSING INTERVENTIONS

LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY) UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY)
FOR RATIONALE

1.

2.

10

Self-care deficit related to activity intolerance due to


decreased cardiac output and subsequent dyspnea and
fatigue upon exertion.

Theory:
Activity intolerance may impair a clients recovery because it can
result in prolonged hospitalization, increased risk of complications
from immobility and delayed rehabilitation (Potter & Perry, 2009
p. 1055). Furthermore, it has the potential to negatively impact a
persons ability to carry out any or all of Hendersons fundamental
needs which include: breathing normally, eating and drinking
adequately, eliminating body wastes, moving and maintaining a
desirable body position, sleeping and resting (Blais et al, 2006).

Theory:
According to Faye Glenn Abdellahs Nursing theory: Typology of
21 Nursing Problems, it is a nursing responsibility to create and
Imbalanced nutrition: More than body requirements,
maintain a therapeutic environment (Blais et al, 2006). Client has
related to excessive caloric intake, as evidenced by
clients central obesity and elevated cholesterol and blood an impaired ability to take care of himself so one of the nurses
care goals should be to help the patient help himself.
pressure.

Theory:
According to Myra Levines Conservation model, the goal of
patient care should be to promote adaptation and maintain
wholeness using the principles of conservation, eating and
drinking adequately are essential to a persons holistic being
(Blais et al, 2006). An alteration of nutrition: more then body
requirements represents a significant risk to the clients health
maintenance and adequate nutritional uptake.
3.

Altered self-concept related to obesity and presence of


Holter Monitor.
Theory:
According to Hendersons fundamental needs model, eating and
drinking adequately are essential to health maintenance (Blais et
al, 2006). An alteration of nutrition: more then body requirements
represents a significant risk to the clients health maintenance and
adequate nutritional uptake.

4.

Theory:
Risk for caregiver role strain related to patients increasing According to Jane Watsons transformative theory of nursing,
care needs and dependency.
nursing can be a transforming process through which both the
patient and nurse can be changed. Her theory of nursing practice,
formally known as the "Theory of Human Care," outlines basic
premises of nursing and combines a humanistic and scientific
approach to patient care. According to Watson, caring is a nurse's
identity and when caring is fully actualized, a patient's world can
become more secure, brighter, richer and larger (Blais et al,
2006).

Theory:
Florence Nightingale saw the role of nursing as having charge of
somebodys health based on the knowledge of how to put the
body in such a state as to be free of disease or to recover from
disease (Potter & Perry, 2009). By educating the client about the
disease process, complications and treatment needs the nurse
provides knowledge that places the client in charge of his health.

ASSESSMENT DATA

11

NURSING

PLAN

INTERVENTIONS

RATIONALE FOR

EVALUATION

SUBJECTIVE/
OBJECTIVE

DIAGNOSIS

Subjective:
Whenever I try to do
anything, I get so out of
breath.

Self-care deficit
related to activity
intolerance due to
decreased cardiac
output and
Objective:
subsequent
Dsypnea, respirations > dyspnea and fatigue
20 min upon mobility. upon exertion.

Subjective:
I eat whenever I feel
stressed.

Imbalanced
nutrition: More than
body requirements,
related to excessive
Objective:
caloric intake, as
Weight 139.822 kg
evidenced by
Total cholesterol > 240 clients central
BP: 156/113
obesity and
elevated cholesterol
and blood pressure.

OUTCOME
CRITERIA (CLIENT
CENTERED)
Patient will identify
controllable factors
that cause fatigue.
Patient will have his
self-care needs met.

INTERVENTIONS

1. Teach patient how to 1. These energy


Patient is
conserve energy while conserving methods proficient in
performing ADLs, such will reduce the
conserving energy
as sitting in a chair while metabolic and oxygen and performs selfdressing, wearing
needs of the heart,
care and ADLs
lightweight clothing that allowing the client the with little to no
fastens with Velcro, etc. vitality to care for
symptoms of
himself more.
fatigue; patients
2. Teach patient
BP, HR, and RRs
exercises for increasing 2. These exercises will remain within
strength and endurance. improve breathing and normal
(Sparks & Taylor, 2009) promote general
parameters during
physical
periods of activity.
reconditioning.
(Sparks & Taylor,
2009)

Patient will adhere to 1. Have dietician


1. These interventions Patient and health
a low cholesterol/ low calculate target caloric and planning serve to care professional
fat diet, will
intake and discuss meal help the patient reach establishes a
participate in a
planning.
a desirable weight.
weekly weight
selected exercise
loss goal; patient
program 4x week,
2. Help patient to select 2. This aids in weight adheres to the
and will experience a an ideal exercise
loss and also offers an prescribed diet
therapeutic reduction program.
alternative to eating to and exercise
in weight, in BP, and
alleviate stress.
regimen and
in cholesterol levels. 3. Weigh patient weekly,
demonstrates a
or as prescribed.
3. Weighing the
therapeutic
(Sparks & Taylor, 2009) patient serves to
reduction in BP
monitor the
and cholesterol
effectiveness of the
levels.
diet and exercise plan.
(Sparks & Taylor,
2009)

Subjective:
Altered self-concept Patient will voice
I already felt ugly but related to obesity
positive feelings
now I have to wear this and presence of
about self, report a

12

(NURSE CENTERED)

1. Explore patients
1. Evaluates patient Patient describes
usual coping
and gives the
how feelings
mechanisms in times of opportunity to discuss about self have

stupid heart device for


everyone to see!

Holter Monitor.

Objective:
Weight 139.822 kg
Presence of central
obesity
Holter monitor in place

Subjective:
I live with my mom and
I know she is old, but
she ends up taking
more care of me than
herself..

Objective:
Client lives with mother,
is currently
unemployed, and is
financially/ physically
dependant on his
mother.

13

sense of control over stress.


life events, and will
voice acceptance of 2. Encourage patient to
the Holter Monitor. express feelings about
self (past and present).
3. Demonstrate
methods of concealing
the Holter Monitor from
the public, and explain
its presence is not
permanent.
(Sparks & Taylor, 2009)

Risk for caregiver


role strain related to
patients increasing
care needs and
dependency.

Caregiver will identify 1. Encourage caregiver


formal and informal to discuss coping skills
sources of support used to overcome
and will report
similar stressful
increased ability to situations in the past.
cope with stress
related to her sons 2. Refer patient
health care/ self-care caregiver to a
needs.
psychiatric liason nurse,
support group, or home
health agency.
(Sparks & Taylor, 2009)

additional positive
methods of coping.
2. Self-exploration
encourages the
patient to consider
future change.
3. Allows patient to
feel more selfconfident wearing it,
and knowing that this
treatment is short-term
will increase
compliance.
(Sparks & Taylor,
2009)
1. This reflection will
build confidence for
managing the current
situation.

2. This will help the


caregiver to foster
mutual support
emotionally and in
caring for the patient.
(Sparks & Taylor,
2009)

changed since
current health
problem began
and voices
understanding of
Holter Monitors
use, importance,
and the ease with
which it can be
concealed.

Caregiver uses
appropriate
coping skills for
each stressful
situation and
utilizes available
support systems.

Mother: S.J.
Age: 58 years
old
Health Status:
Alive, obese
High
cholesterol,
osteoporosis.

GENOGRAM

Patient: R.J.
Age: 35 years old
Diagnosis: Severe Cardiomyopathy
(dilated)
Health History: Congestive heart failure,
high cholesterol, high blood pressure,
heart palpitation, gout, chronic snoring,
alcoholism, and tobacco use.

Son: T.J.
Age: 16 years old
Health Status:
Obese, High cholesterol,
high blood pressure.
14

Daughter: K.J.
Age: 17
Health Status:
Iron-deficiency
anemia, smoker,
pregnant.

Father: K.J.
Age: 62 years old
Health Status:
DeceasedHypertension/MI.

Sister: AJ.
Age: 38 years
old.
Health Status:
Deceased- car
accident.

Daughter: M.J.
Age: 19
Health Status:
Obese. Smoker.

REFERENCES:
Blais, K. (2006). Professional nursing practice: Concepts and perspectives. Upper Saddle River, N.J:
Pearson/Prentice
Hall.
Porth, C., & Porth, C. (2007). Essentials of pathophysiology: Concepts of altered health states.
Philadelphia:
Lippincott Williams & Wilkins.
Potter, P.A., & Perry, A.G., (2009). Fundamentals of nursing (7th ed). St. Louis: Mosby & Elsevier.
Sparks, S.S., & Taylor, C.M., (2009). Nursing diagnoses reference manual (8th ed). Philadelphia: Lippincott
Williams &
Wilkins.
Brunner, L.S., & Smeltzer, S.C., (2010). Brunner & Suddarths textbook of medical-surgical nursing.
Philadelphia: Wolters
Kluwer Health/ Lippincott Williams & Wilkins.

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