NURSING CARE PREPARATION

Student Name: Elizabeth B. Archibald Date of Care: 11/7/17

Unit/Room Number: 313 Date of Admission: 11/05/17

Age: 76 y/o Ethnic/Cultural Preferences: Caucasian
Gender: female Allergies: PCN, SULFA, LOOP DIURETICS
Eriksons Developmental Level: Code Status: Full code
Ego integrity versus despair

Primary Diagnosis: AFIB, with RVR--- admitted for rate control and started on a Cardizem drip and then transferred over
to amlodipine (rate control) elevated D dimer and BNP.

and Bronchitis. Probable Pneumonia, pending culture results.

Co-morbidities: CHF, HTN

Discharge Plan: Possible discharge tomorrow

Integrated Pathophysiology:

Patient was admitted for rate control and was started on a Cardizem drip. She had an elevated D dimer, and BNP. The D-
dimer indicates an elevation in coagulation in the body. BNP is a hormone secreted in your brain in response to elevated
blood pressure. This is a compensatory mechanism to help the body to decrease BP to normal ranges.

AFIB with RVR

Atrial fibrillation is a heart condition where the electrical conducting system of the heart is not functioning adequately.
Instead of the atrium contracting normally, it is quivering. This leads to pooling of blood, and potential for clot
formation. Clot formation can lead to pulmonary embolisms. Patients D-dimer results reflect that the body has already
formed clots. Because of this, patient has been started on Coumadin, and Lovenox. Patient was placed on continuous
ECG monitoring to monitor her hearts electrical conduction.

Rapid ventricular rate is another abnormality in electrical conduction of the heart that occurs secondary to atrial
fibrillation. The heart rate with Afib and RVR can be up to or greater than 200 beats per minute.

These abnormalities are dangerous because there is a greater chance of clot formation, and PE. Also, because the heart
is not completing a full diastolic/systolic function, the heart is not filling up with an adequate amount of oxygenated
blood, and is therefore, not delivering oxygen rich blood to nourish the tissues of the body.

The goal with this patient is to slow her heart rate, and decrease her blood pressure. The idea is that her heart can fill
with blood fully to be able to nourish the body to meet its needs.

Data Collection
Diet (Type): Cardiac diet IV: NS 60 ML/hr
I&O: BID CBG: None
Fall Risk/Safety Precautions: Fall Risk Activity: Ambulate in room only TID with assistance
Wound Care: None Oxygen: none
Drains: None Last BM: AM 11/7, large, formed, light grey/brown.
Other Tubes: None

ASSESSMENTS
Integumentary: Head and Neck:
Skin is in good condition. Pink, warm, hydrated. Patients trachea is midline.
Some bruises are located on lower and upper bilateral Hair thick, scalp clean.
arms secondary to venipuncture. LN non-palpable
Face symmetrical, and expression calm.

Ear/Nose/Throat: Thorax/Lungs:

Patient has all her natural teeth. Wheezes throughout lung field. Right upper worse than
She can swallow on her own, and is not at risk for any other field. Crackles is posterior bilateral bases.
aspiration. Patient is coughing up copious amounts of yellow sputum.
Patient does not have a hearing problem. She states that her chest hurts.

Patient is not on O2.

Patients costovertebral angle is 2:1 ratio.

SOB with exertion.

Cardiac: Musculoskeletal:
Dysrhythmia auscultated.
Peripheral pulses bounding +3, but equal. Patient states that she has an old rib injury.
Tachycardia present. She is able to ambulate without difficulty, and is not a fall
Trace edema to lower extremities risk.
JVD present/ measured at 5 cm.
CRT < 3 seconds.

Genitourinary: Gastrointestinal:
Output is excessive due to diuretics. Normoperistaltic sounds in all four quadrants.
No abdominal pain with auscultation.

Neurological: Other (Include vital signs, weight):

A&O X4 T 98.9 F
All cranial nerves intact. P 133
Strength to upper and lower extremities present, WNL. R 16
No paresthesia noted. BP 154/80
SPO2 sat 96% RA
Pain 2/10
 CURRENT MEDICATIONS

Generic & Classification Dose/Route/ Onset/Peak Intended Adverse reactions Nursing Implications for this
Trade Name Rate if IV Action/Therapeuti client.
c use.
EXT/REL Onset 30
Gauifenesin/ Therapeutic: allergy, 1200 MG PO mins Reduces viscosity dizziness Look for orthostatic
Mucinex cold, and cough BID Peak of tenacious hypotension before having
remedies, expectorant Unknown secretions by patient ambulate
increasing
respiratory tract
fluid.

Enoxaparin/L 40 MG SQ Onset: bleeding Monitor skin for bruising,

ovenox PFS Classification 0900 Unknown Prevention of bleeding
Therapeutic: Peak: 3-5 hr. thrombus
anticoagulants formation.
Pharmacologic:
antithrombotic,
heparins (low
molecular weight)

40 MG PO Abdominal pain Palpate abdomen with head

Pantoprazole Therapeutic: antiulcer 0900 Onset: 2.5 hr. Erosive to toe to assess for pain
/Protonix agents Pharmacologic: esophagitis
proton-pump inhibitors Peak: associated with
unknown GERD.

25 MG PO Electrolyte imbalances Monitor labs for electrolyte

NF- Edecrin Therapeutic: diuretics BID Onset: 30min Edema due to imbalances.
heart failure
Pharmacologic: loop Peak: 2hr
diuretics
 10 MG PO Peripheral edema Check extremities for edema
Amlodipine Therapeutic: 0900 Onset: management of with daily head to toe.
antihypertensive unknown hypertension
Pharmacologic:
calcium channel Peak: 6-9 hr
blockers

25 MG TAB Diarrhea Monitor stool daily for

Carvedilol/Co Therapeutic: PO BID Onset: within Hypertension. HF consistency
reg antihypertensive 1 hr.
Pharmacologic: beta
blockers Peak: 12hr

500 MG PO Onset: Rapid Treatment of nausea Monitor for GI disturbances

Levofloxacin/ Therapeutic: anti- 0900 Peak: 1-2 Pneumonia before each meal.
Levaquin infective hours
Pharmacologic:
fluoroquinolones
 DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date Lab Test Patient Values/ Interpretation as related to Pathophysiology
Normal Values Date of care
11/7 Sodium 136 Normal
135 145 mEq/L
11/7 Potassium 4.3 Normal
3.5 5.0 mEq/L
11/7 Chloride 103 Normal
97-107 mEq/L
11/7 Co2 25 Normal
23-29 mEq/L
11/7 Glucose 86 Normal
75 110 mg/dL
11/7 BUN 18 Normal
8-21 mg/dL
11/7 Creatinine 1.06 Normal
0.5 1.2 mg/dL
11/7 Calcium 8.6 Normal
8.2-10.2 mg/dL
11/6 Total Protein 5.6 LOW --- protein is present in the interstitial space
6.0-8.0 gm/dL (edema) as transudate.
11/6 Albumin 3.4 LOW --- protein is present in the interstitial space
3.4-4.8gm/dL (edema) as transudate.
11/6 Alk Phos 56
25-142 IU/L
11/6 SGOT or AST 15
10 48 IU/L
11/7 WBC 4.9
4.5 11.0
11/7 RBC 3.59 Low --- Fluid is not being pumped effectively by the
male: 4.7-5.14 x right side of the heart. There is a backup of blood
10 into the vasculature. This leads to low RBC count by
female: 4.2-4.87 dilution.
x 10
11/7 HGB 11.1 Low --- Fluid is not being pumped effectively by the
male: 12.6-17.4 right side of the heart. There is a backup of blood
g/dL into the vasculature. This leads to low HGB count by
female: 11.7- dilution.
16.1 g/dL
11/7 HCT 32.9 Low --- Fluid is not being pumped effectively by the
male: 43-49% right side of the heart. There is a backup of blood
female: 38-44% into the vasculature. This leads to low HCT count by
dilution.
11/7 MCV 91.6 Normal
85-95 fL
11/7 MCH 31 Normal
28 32 Pg
11/7 MCHC 33.9 Normal
33-35 g/dL
11/7 RDW 5.5 Low --- This is secondary to the low RBC
11.6-14.8%
 11/7 Platelet 169
150-450

DIAGNOSTIC TESTING

Date UA Interpretation as related to

Normal Range Results Pathophysiology cite reference &
pg #
11/5 Color/Appearance Clear Yellow/turbid
yellow/clear-
cloudy
11/5 pH 5.0-8.0 5.5
11/5 Spec Gravity 1.005-1.020 >1.030 High --- urine is dilute secondary to
diuretic.
11/5 Protein NEG 2+ High indicated risk for heart
disease.
11/5 Glucose NEG NEG Normal
11/5 Ketones NEG NEG Normal
11/5 Blood NEG NEG Normal
11/5 Bacteria NEG 1+ Dirty catch
Date Other Interpretation as related to
(PT, PTT, INR, ABGs, Normal Range Results Pathophysiology
Cultures, etc)
11/5 D-Dimer Less than or Elevated See patho above
equal to 500
ng/mL

11/5 BNP Less than 125 Elevated See patho above

pg/mL

11/7 PT 9.3-11.4 10.9 sec Normal

11/7 INR 1.08 0.9-1.2 Normal
11/7 Sputum sample Pending
Date Interpretation as related to
Radiology Results
Pathophysiology
11/5 EKG-12 lead Afib and RVR See patho above
Continuous Telemetry Afib and RVR See patho above
11/5 Chest Rads Pulmonary edema See patho above

DAR NURSING PROGRESS NOTE

11/07/2017 @ 1000
Data: Patient had a non-patent IV to right hand, but patient requires an IV because she is on a medication to slow her
heart rate.
This requires emergency venous access.
Action: Patient educated on reasons for needing another IV. Nursing student prepared, and placed 20 G IV into left
wrist.
Response: IV was patent and flushed well. Patient denied pain.

11/07/2017 @1100
Data: Patient was given an incentive spirometer to improve lung function.
Action: Student nurse discussed how incentive spirometer works, what the goal of the treatment is, and how to use the
apparatus.
Response: Patient maintained ball of spirometer in the best range for 5 seconds. She will continue to use I.S. 10 times
per hour.

11/07/2017 @1300
Data: With exam, it is noticed that patient has a distended artery in her neck. Student nurse thinks that it is a carotid
artery pulsating.
Action: Student nurse asks charge nurse about finding. Doctor overhears conversation and states that there is no way it
would be a carotid artery due to muscle coverage- it would have to be JVD.
Response: Student realizes that she has never seen JVD in the clinical setting. Explains to patient the finding and
measure the JVD. It measured at 5 CM.

PATIENT CARE PLAN

Patient Information:
Afib with RVR, CHF, HTN, pulmonary edema, bronchitis, pneumonia.

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).

Problem #1 Decreased cardiac output R/T decreased contraction of atrium AEB pooling of blood in the right
atrium, clot formation, and signs of edema.

Desired Outcome: Patients edema will decrease within my 12-hour shift.

Nursing Interventions
1. Administer diuretics as prescribed.
2. Keep patient on a low salt, cardiac diet.
3.Administer beta blockers as prescribed to decreased the
workload of the heart, and therefore, decrease need for O2 by
the heart.
Client Response to Intervention
1. Patient states that she has noticed a difference
since yesterday while being on her diuretic.
2. Patient wanted salt with her lunch, but instead
used a no salt season.
3. Patient is compliant with medication
administration.

Evaluation:
Patients edema was only trace today, but was 2+yesterday.

Problem #2 Impaired gas exchange R/T fluid in the pulmonary interstitial space AEB radiographs that
diagnose pulmonary edema, and dyspnea with exercise.

Desired Outcome: patient will

Nursing Interventions Client Response to Intervention
1. Allow for frequent resting in between activity 1. Patient did well with pacing herself.
2. Use incentive spirometer 10 times per hour. 2. Patient did well keeping the ball in the best
place.
3. Administer antibiotics and diuretics as ordered. 3. Patient is compliant with her medication
administration.
Evaluation:

Patients SPO2 stayed in the 90 percentile today. She only complained of being SOB twice. She recovered quickly post
dyspneic episode.