Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Son reported patient exhibited “mood swings” and periods of “confusion.”  Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased grips/weakness on left side

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Post-CVA

Problem

Decreased cardiac output

Long Term:

Client will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for the client; strong peripheral pulses, and an ability to tolerate activity without symptoms of dyspnea, syncope or chest pain by [date], 16:00.

-Assess client for symptoms of heart failure and decreased cardiac output; listen to heart sounds, lung sounds, note symptoms including dyspnea, orthopnea, PND, Cheyne-Stokes, fatigue, extra heart sounds, weakness, crackles in the lungs, and JVD.

-Monitor I & O hourly.  Decreased cardiac output results in decreased renal perfusion and urine output.

-Observe for atypical pain presentation as patient is a diabetic with several comorbidities

-Monitor lab data closely, especially BNP and K+.

-Administer oxygen as needed per physician’s order

-Place patient in Fowler’s or semi-Fowler’s position to decrease work of breathing.

R/T

Altered electrical conduction

Short Term:

Client will remain free of side effects of medications used to achieve adequate cardiac output throughout shift.

-Review patient’s medication list

-Check blood pressure, pulse and condition before administering cardiac medications such as ACE inhibitors, calcium channel blockers, and beta blockers.  Notify physician if heart rate or BP is low.

-Administer IV fluids cautiously and observe to s/s of fluid overload

-Assess for s/s of adverse medicinal effects

AEB:

Left side extremity weakness, right side hemiparesis, altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), elevated BUN (41), elevated creatinine (1.73), dysrhythmias, altered respiratory rate (24) and presence of 2x3, 1 inch depth stage II ulceration on coccyx, unstageable wound on the right heal, presence of multiple skin tears on the upper extremities, decreased Hgb (10.2), decreased albumin (2.0), elevated blood glucose (185) and client is NPO.