R.S. 61 YO. Female. Ht. 68 inches. Wt. 101.7kg. BMI 35.4 Full Code

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Human Nutrition

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milkshake.

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THE CIRCULATORY SYSTEM

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Cardiology

luonut craig crowther

R.S. 61 YO. Female. Ht. 68 inches. Wt. 101.7kg. BMI 35.4 Full Code

Functional Problems

Second Priority Problem - At risk for further complications hypokalemia & AKI

SMART goal - bring potassium level to normal limits (3.5-5) before discharge.

Goal continued, medicated during my shift with 40meq potassium po and 10meq IV. Brought level up to 3.2.

Nursing Intervention#2 - Regulate Patient Nutrition

Teaching #2 - Teach patient to read nutrition labes

rationale - teach the patient to take charge of their nutrion

Teaching #1 - teach patient which foods are high in potassium leafy greens, nuts, etc. - teach patient about low sodium - salt substitutes

rationale - regulate labs, prevent dysrhythmias, lead a healthy life

Collaborative Intervention #2 - work with patient and family to implement a heart healthy, kidney healthy diet.

Collaborative Intervention #1 - work with dietary to provide a low sodium, high potassium, cardiac diet

Rationale - keep potassium and sodium levels under control

Nursing Intervention#1 - Monitor Lab Work

Teaching #2 - Teach patient about medication resources

Teaching #1 - teach patient organization for medication times, make a calendar/schedule

rationale - medication adherence

Collaborative Intervention #2 - work with patient and family for at home medication adherence

Collaborative Intervention #1 - work with doctor and pharmacy to provide potassium supplementation.

Rationale - monitoring lab work will tell the nurse what interventions need to be done to fix the specific lab levels

First Priority Problem - Heart Failure

SMART goal - keep systolic blood pressure over 100 for entirety of hospital stay and once at home.

systolic blood pressure over 100 the entirety of my shift, this is a continued goal.

Nursing Intervention #2 - Prevent atelectasis

Teaching #2 - safety when ambulating - non slip socks, utilize any assistive devices, walk with someone not alone

Rationale - to prevent falls

Teaching #1 - benefits of movement

rationale - to prevent atelectasis and work the edema out of the interstitial spaces.

Collaborative Intervention #2 - encourage patient to utilize deep breathing / incentive spirometer alone, with family or staff help

Collaborative Intervention #1 - encourage the patient to work with PT/OT, techs, students, or other nurses to ambulate as much as possible

Rationale - CHF patients are at risk for atelectasis when they are in the hospital due to being sedentary

Nursing Intervention #1 - Monitor I & O

Teaching #2 - Do not dump urine with out measuring

Rationale - We need to measure all urine to be able to identify and prevent fluid volume overload

Teaching #1 - How to urinate in the hat

Rationale - We need to collect the urine in a hat for measurement

Collaborative Intervention #2 - work with other nurses, techs, students, family to measure all oral intake for the patient - report all oral intake to the nurse for charting

Collaborative Intervention #1 - work with other nurses, techs, students, family to measure urine output for the patient - report all output to the nurse for charting

Rationale - avoid fluid volume overload - do not make a sick heart work harder

Assessment

See SBAR for more information

Respiratory

Thorax is symmetrical, lung sounds diminished No crackle heard See vital signs for RR/Spo2 bowel sounds hypoactive

Cardiovascular

Warm to the touch, normal color, no odor, skin turgor is normal, hair is normal, nails are normal - cap refill delayed Heart WNL - sinus rhythm - auscultation - no extra heart sounds normal JV - no distention - Swanline in R- IJ Radial Pulses - WNL Pedal Pulses - +1 weak Right Arm has lymphedema Left Arm edema has decreased Lower extremities - mild edema - bilaterally Pain 9/10 - headache causing nausea, sleep makes it better

Lab Work

Blood Glucose - ACHS - most recent 196 Mixed Venous Blood Gas - ABE - 7.3 PCO2 - 55 pH - 7.41 PO2 - <43 SVO2 - 75.2 Abnormal Lab Findings BUN - 29 CREAT - 1.19 Na - 135 K+ - 3.1 Protein - 6.3 GFR - 52 Proth - 14.6 RBC - 3.76 Plat - 133 Lump - 0.39 High Low normal

Vital Signs

BP - 107/62 HR - 93 Temp - 97.4 RR - 20 Spo2 - 97% SVR - 1200 SVo2 - 79% CI - 3.1 CO - 7.7 CV - 16 PAP 51/23

Admitting Diagnosis

Priority Diagnosis - Acute Exacerbation of Systolic & Diastolic Congestive Heart Failure EF 20 %

Presented to hospital - SOB, sleeping in recliner, bilateral extreme edema,

Patho - Systolic heart failure - the left side of the heart's contractility is decreased resulting in decreased EF. Diastolic heart failure - left side of the heart muscles are too stiff to relax which impedes the filling of the atria & ventricle.

Medical History

Type 1 Diabetes 2015 Atypical lobular hyperplasia Breast Cancer 2018 Right Mastectomy 2019 Anxiety Asthma (Chronic) Hypertension Hypotension Hypothyroid (chronic) Systolic & Diastolic Congestive Heart Failure r/t chemotherapy from breast cancer