PATIENT INFORMATION Name: Arthur Jackson 73 y. o.

Male Admitting DX: CHF and Uncontrolled A-Fib Medical HX: MI, 4 vessel CABG, Type II DM, HTN, Gout, Hiatal Hernia, A-Fib, Enlarged Prostate Admit Date: 09/09/2011

Diagnostic Test Results: CXR: Reveals moderate pulmonary vascular congestion, cardiomegaly, no signs of atelectasis or infiltrate noted EKG: Atrial Fibrillation ventricular rate 124 no ischemic changes or ectopy noted ECHOCARDIOGRAM: Reveals normal valvular function, irregular heart rhythm, increased volume in L ventricle, Ejection fraction 45%, no clots seen, TEE recommended for further evaluation DUPLEX ULTRASOUND: No Clots noted bilaterally, bilateral popliteal arteries have decreased blood flow

Medications: Lisinopril 5mg PO BID Digoxin 0.125mg PO Daily Coumadin Dosage dependent upon current INR values Lasix 40mg IV BID K-DUR 20 mEq Daily Proscar 5mg daily Glucophage 1000mg PO BID Protonix 40mg IV Daily Coreg 12.5mg BID

Vital Signs BP 188/111 P 122 irregular R 28 labored O2 Sat 92% on RA

T 97.6

Diet: 1800 ADA, Low Sodium 1500ml / 24 hours fluid restriction STRICT I&Os

Abnormal Lab Results: PLT 100,000 (Norm 150,000-450,000) MCH 31.2 (Norm 32-36) BUN 55 (Norm 8-21) Creatinine 1.8 (Norm 0.6-1.2) Digoxin 2.3 (Norm ) PT 17.8 (Norm 11-15 sec X 2-2.5) INR 1.7 (Norm 1 Coumadin 2-3) PTT 38.4 (Norm 60-70 sec) Troponin 0.89 (>0.5 is critical) Myoglobin 23 (Norm 0-2.5) BNP 1385 (Norm <100) UA pending

Patient Goal Get released from the hospital Evaluation Patient was not discharged during shift so the goal has not been reached yet. Continue with current nursing plan.

#1 Decreased Cardiac Output R/T A-Fib AEB irregular heart rate GOAL: The patient will verbalize the S/S of A-Fib and the importance of Digoxin and Coumadin prior to discharge INTERVENTIONS: Assess Blood Pressure and Heart Rate monitor Labs (PT and INR Digoxin) A sudden change in BP can indicated a deterioration in the patients condition; The heart rate is an indication of the cardiac output and the degree to which the body will be oxygenated; Labs will show therapeutic levels of the medications Give Medication: Coumadin, and Digoxin and teach the patient about the importance of taking as its prescribed Coumadin is to help prevent blood clots as a result of A-Fib Digoxin will help improve the cardiac output by increasing the contractility of the heart By teaching the patient each time the medication is administered the importance of the medications are reinforced repeatedly Elevate Legs for 15 minutes every hour This will help with venous return and keep the blood from pooling in the legs EVALUATION: BP decreased slightly 160/90; HR 89; PT and INR are not within therapeutic ranges; Digoxin level is high- doctor was notified and said to continue administering the medication. The patients legs were elevated 15 min Q hour and the patient tolerated it well. ADLs were clustered to decrease the cardiac demand. GOAL EVALUATION: Continue working on this goal until the patient is able to verbalize the importance of taking his medications as prescribed

#2 Excess Fluid Volume R/T Heart failure AEB Weight gain of 27lbs and crackles in the lungs GOAL: Patient will have a total fluid intake of 1500ml/24 and sodium intake of less than 2g INTERVENTIONS: Assess Lung sounds, SaO2, I/Os, and weight A change in lung sounds can indicate either an increase or decrease in fluid volume in a CHF patient; The SaO2 will show the amount of oxygen that is circulating in the blood and the level at which the tissues are receiving O2; a sudden weight gain can indicate fluid retention; CHF patients need to monitor I/Os to ensure there isnt a fluid over load. Give Medication: Lasix and K-DUR; teach the importance of taking Lasix and a potassium supplement when directed Lasix is a diuretic that works at the loop of Henle it is very important to monitor K+ levels and take potassium as needed, because when a patient is also taking Digoxin hypokalemia can lead to dig toxicity Provide low sodium diet along with a daily intake <2g Sodium is directly related to water retention and when a patient is retaining too much fluid it is important to maintain a low sodium diet. EVALUATION: Lung sounds were clearing; SaO2 levels were 98% on RA, and patient had in total intake of 1400ml and a total output of 7300ml, a weight loss of 6kg. Patient tolerated Lasix and K-Dur well, and verbalized the reason he was taking the medications. Patient had a total sodium intake of 1975mg and verbalized the importance of eating fresh fruit and vegetables, and eating less processed foods and demonstrated how to read a food label. GOAL EVALUATION: The goal will be continued. The patient had aintake of <1500ml and a sodium intake of <2000mg the goal was reached but will be continued, patient teaching will also continue till discharge

#3 Activity Intolerance R/T Generalized weakness AEB fatigue, and SOB GOAL: Patient will be demonstrate clustering of activities and be able to perform ADLs throughout shift. INTERVENTIONS: Assess BP, HR and O2 sats, before and after activity Orthostatic hypotension can occur from the medications (vaso dilation and fluid shifts from diuretics) Give medications: Glucophage do maintain a proper glucose level The patient must take his oral diabetic medication to maintain stable glucose levels, during periods of illness the levels may change and must be monitored closely Teach patient how to cluster activities in order to decrease the energy required to perform tasks By clustering the activities the patient will be able to perform his own ADLs and rest in between his periods of exertion. EVALUATION: The patient had no episodes of orthostatic hypotension, patient denied dizziness, and was able to perform ADLs without assistance. Patient maintained O2 sats >97% on RA during activities; Patient took Glucophage and had a blood glucose level of 97, patient verbalized the reason for taking Glucophage this will help keep my sugar levels normal; The patient verbalized and demonstrated how to cluster activities in order to minimize fatigue, patient also asked about an exercise program he could start and was given printed pages explaining how to exercise safely based on CHF GOAL EVALUATION: The goal was met, but the diagnosis needs to be continued through discharge with follow up teaching in home.

#4 Deficient Knowledge R/T Patient not going to doctors appointments AEB: Patients verbalization of not knowing that he had CHF, and asking what that means GOAL: Patient will understand and verbalize causes, treatments, and care related to CHF INTERVENTIONS: Assess knowledge of causes, treatment, and care related to CHF This provides a base for educational planning Educate about normal heart and circulation, CHF disease process, symptoms, dietary modifications, activity guidelines, medications, goals, therapy and community resources This will help to reduce symptoms and readmissions for exacerbation Encourage Questions This will help verify understanding of information EVALUATIONS: The patient said I didnt know I had CHF I thought that I was just gaining weight because I like to eat PT stated that he didnt know that it was that important to go to the doctors because its so expensive and he didnt want to go all the time. The patient was given an information packet that contained community resources for in home services, he was also provided a packet that contained information on CHF and diabetes. The information was read together and then the patient wanted to read through it again and write down questions GOAL EVALUATION: The goal has not been met and needs to be continued beyond discharge, the patient received a referral for home health and a social worker will be in before discharge to set up additional services.