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NURSING 404

MEDICAL-SURGICAL NURSING
Guide for Weekly Clinical Prep/Care plan (clinical paper)
Due one week after caring for the patient
Michelle Eva Morholt, WCSN goals for the day:
I will by end of this clinical day:
1. Appropriately document in EPIC.
2. Discontinue ROs pacemaker wires, chest tubes, and arterial line.
3. Manage ROs scheduled, continuous and PRN medications.
List the interventions that you would like to accomplish with your patient that you will
require assistance with performing:
1. See above listed goals.
I. General patient information
Age: 61 yo Sex: Male Week of clinical 4
Admitting diagnosis:
Coronary artery disease (CAD)
Non-ST elevation myocardial infarction (NSTEMI)
Surgery (if applicable)
Current: Monday April 6, 2015: Coronary artery bypass grafting x 5 with selective
coronary angiography and Left heart catheterization.
Description: Left internal mammary artery to bypass diagonal LAD
Saphenous vein to bypass distal circumflex & OM
Extubated without complications.
Past Surgical History:
N/A
Height: 1.854 meters (61)
Weight: 149.7 kg (330 lbs)
Allergies:
Penicillin (Hives/Swelling)
Code status: Full Code
1. Chief complaint (Why did the patient come to the hospital?)
RO presented to emergency department on 4/5/2015 with complaints of severe
chest pain. After ECG it was noted that RO had no ST elevations but had
experienced a myocardial infarction (NSTEMI).
2. Review general health (past medical history; other health problems)
Health problems:
Hyperlipidemia
Atrial fibrillation
3. Potential medical/psycho/social/cultural barriers to care:
Polypharmacy
Comorbidities
Necessity for multiple lifestyle changes including diet and exercise

4. Brief pathophysiology:
Primary Medical Diagnosis: Coronary artery disease (CAD)
Pathophysiology: Coronary artery disease (CAD) is a chronic process characterized by
atherosclerosis in the epicardial coronary arteries. Atherosclerotic plaques, the hallmark of
atherosclerosis, progressively narrow the coronary artery lumen and impair antegrade myocardial
blood flow. The reduction in coronary artery flow may be symptomatic or asymptomatic, occur
with exertion or at rest, and culminate in a myocardial infarction, depending on obstruction
severity and the rapidity of development (Porth, 2011, p. 192).
Secondary Medical Diagnosis: Non ST elevation myocardial infarction (NSTEMI)
Pathophysiology: A myocardial infarction (MI) also referred to as a heart attack is myocardial
necrosis resulting from abrupt reduction in coronary blood flow to part of the myocardium.
Infarcted tissue is permanently dysfunctional; however, there is a zone of potentially reversible
ischemia adjacent to infarcted tissue. A non-ST elevation myocardial infarction (NSTEMI) is
myocardial necrosis (evidenced by cardiac markers in blood; troponin I or troponin T and CK
will be elevated) without acute ST-segment elevation or Q waves. ECG changes such as STsegment depression, T-wave inversion, or both may be present.
Tertiary Medical Diagnosis: Hyperlipidemia
Pathophysiology: Hyperlipidemia is the presence of high levels of cholesterol in the blood.
Diagnosis is based on levels of total serum cholesterol, LDL, HDL, and tryglicerides as seen in a
fasting serum lipoprotein profile. Hypercholesterolemia presents increased risk for coronary
heart disease, which is characterized by the buildup of fatty plaques in the coronary arteries,
causing restriction of blood flow. Risks for developing hyperlipidemia include poor nutrition,
genetics, obesity, medications, and metabolic conditions (Porth, 2011, p. 168).
Quaternary Medical Diagnosis: Atrial fibrillation

Pathophysiology:
In the heart, typically, conduction begins with a small cluster of cells in the right atrium called
the sinoatrial node. The SA nodes electrical impulses are conducted to the atrioventricular node
(AV node) (Martini et. al., 2011, p. 561). The AV node depolarizes and the electrical conduction
is sent through the Left and Right branched of Bundle of His and Purkinje fibers and results in
the contraction of the left and right ventricles (Martini et. al., 2011, p. 562). Any muscle in the
heart is capable of initiating an electrical impulse. When the AV node receives unsynchronized
electrical impulses from multiple cells, the AV node is unable to depolarize and repolarize
efficiently, and causes atrial fibrillation (Porth, 2011, p. 391). The result is irregular
unsynchronized contractions of the ventricles, causing an irregular, high pulse rate, poor tissue
perfusion, and places pt. at risk for developing clots in the left and right atria r/t shortened
diastole resulting in blood pooling and coagulating in the left and/or right atria (Porth, 2011, p.
391). ROs atrial fibrillation is well controlled. In fact he was in normal sinus rhythm since
coming out of surgery.
5. Medications (dose, route, frequency, reason for getting, know nursing implications)
Scheduled Hospitalized Medications:

Acetaminophen (Tylenol): 1000 mg, PO, Q6H. This antipyretic and analgesic is
administered PRN to reduce fever and pain. Hypermetabolic state, chronic severe anemia,
and occasionally activated immune system stimulate an increase of WBCs and cytokines.
Cytokines in turn, stimulate the hypothalamus to increase his core temperature as a
defense against pathogens. Fever increases all VS and metabolism resulting in an
increased risk of dehydration.

Aspirin 81mg, One tablet taken Daily: An Salicylates/ antipyretics, nonopioid


analgesics, NSAID. MOA: inhibits the production of prostaglandins. Decreases platelet

aggregation. Taken as a prophylaxis for MI. Side effects include: GI bleeding, dyspepsia,
epigastric distress, heartburn, nausea. Anaphylaxis, laryngeal edema Tinnitus=overdose. .
Nursing Interventions: pt w/ asthma at risk for hypersensitivity reactions. Monitor
hepatic function. Monitor serum salicylate levels. Assess for bleeding. Prevent injuries.

Coumadin (Warfarin), 5mg PO QHS with INR goal of 2-3 seconds: an anticoagulant
administered for prevention of thromboembolic events that may develop as a result of
blood pooling in ROs right atria secondary to atrial fibrillation. Interferes w/ hepatic
synthesis of Vit. K dependent clotting factors (II, VII, IX & X). Nursing Interventions:
Assess pt. for signs of bleeding and hemorrhage and ineffective tissue perfusion.
Monitor PT Heptatic function and CBC. Risk for injury Antidote: Vit K.

Furosemide (Lasix): 40mg/2mL 0.9% NS, IV, Once: RO required furosemide r/t 1.7kg
weight gain from previous day. This Loop diuretic assists in promoting diuresis and
subsequent mobilization of excess fluid (edema, pleural effusions). Decreased BP.
Common side effects: Aplastic Anemia, Agranulocytosis, Stevens-Johnson Syndrome,
Toxic Epidermal Necrolysis, dehydration, hypochloremia, hypokalemia,
hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis Nursing intervention:
assess fluid status. Monitor daily wt. I&Os. If effective, will lower BP.

Insulin Lispro (HumaLOG) injection, 1-7 units sliding scale, PRN, TID with meals.
Control of hyperglycemia in patients with type 1 or type 2 diabetes mellitus. SubQ
injection. onset:<15 min, peak:1-2 hr, duration 3-4 hr. Frequency varies- administered on
sliding scale based on blood serum glucose levels.
Side Effects: hypoglycemia, anaphylaxis. Nursing Interventions: Administer with food.

Ketorolac (Toradol) 15mg IV Q6H: an NSAID closely related to ibuprofen.


Administered for acute and moderately severe pain. Nursing Interventions: Nephrotoxic.
Maximum daily dose: 120 mg, the maximum combined duration of treatment (for
parenteral and oral) is 5 days - do not increase dose or frequency.

Metolazone (Zaroxolyn) 5mg, PO, Once Daily: a thiazide diuretic that acts primarily to
inhibit sodium reabsorption at the cortical diluting site and to a lesser extent in the
proximal convoluted tubule. Used to address edema caused by cardiac and renal diseases
and hypertension. Nursing Interventions: monitor for hypotension, and urinary output.
Assure indwelling catheter is patent (if applicable). Encourage and assist pt. in urination.

Nitroglycerin: 50mg/250 mL 0.9% NS, IVPB, Once: Arteriolar and venous dilator.
Considered to be the most effective parenteral drug for most hypertensive emergencies
(except myocardial ischemia or renal impairment). It dilates both arteries and veins, and
it reduces afterload and preload. Onset: within seconds. Duration: 2-3 minutes. Nursing
Interventions: Constant monitoring of the blood pressure (hypotension) is required; use
special tubing, headache may occur.

Pantroprazole (Protonix) 40mg, PO, Once Daily: a proton pump inhibitor administered
to decrease gastric acid production. Binds to enzymes in the presence of acidic gastric pH
preventing transport of H ions into gastric lumen. Nursing Interventions: Assess pt
routinely for epigastric or abdominal pain, administer with or without food do not crush,
use for longer than 3 years could lead to vitamin B-12 deficiency and pernicious anemia.
Cocurrent use of PPIs and Coumadin is proceeded with caution r/t increased INR and
prothrombin time that may lead to abnormal bleeding and even death. Monitor for

increases in INR and prothrombin time. ROs labs drawn 4/7 indicate and INR of 1.2
(within range) and a prolonged PT time of 13.9 (range is 10-13).

Phenylephrine (Neo-synephrine) 100mg/250 ML 0.4mcg/kg/min, IVPB, titrated to


parameters: a vasoconstrictor and pressor drug chemically related to epinephrine and
ephedrine but, produces longer effects. Its action on the heart slows the heart rate and
increases the stroke output, producing no disturbance in the rhythm of the pulse. Nursing
Interventions: After titrating phenylephrine throughout shift, RO met parameters to d/c
medication at 1530. Monitor for headache, reflex bradycardia, rebound hypertension,
excitability, restlessness and rarely arrhythmias.

Potassium Chloride 40mg capsule, PO, BID. A mineral & electrolyte replacement/
supplement. Replaces K expelled from loop diuretics (lasix). Side effects: arrhythmias,
abdominal pain, diarrhea, N,V. Nursing Interventions: assess for signs of
hypo/hyperkalemia (3.5-5mEq normal), monitor BP, P, ECG. Continuous monitor for IV
administration.

Simvastatin (Zocor): 40mg, PO, Bedtime: Statins inhibit 3-hydroxy-3-methylglutarylcoenzyme A (HMG-CoA) reductase. This enzyme catalyzes the conversion of HMGCoA to mevalonate, an early and rate-limiting step in cholesterol biosynthesis.
Administered to prevent formation of cholesterol/ hyperlipidemia and prevention of
cardiac events. Nursing Interventions: Assess cholesterol at six weeks. Perform liver
function tests in first year of treatment. In the case of rhabdomyolysis with increased
muscle tenderness and creatine phosphokinase, therapy should be discontinued. Renal
tests for patients with impaired renal function. Eye tests before treatment, after one
month, then annually.

PRN medications: RO required no PRN medication throughout shift.

Bisacodyl (Dulcolax): 10mg, PO, Once Daily. Stimulates peristalsis. Alters fluid and
electrolyte transport, producing fluid accumulation in the colon. Therapeutic Effects:
Evacuation of the colon. Side effects: abdominal cramps, nausea, diarrhea, rectal burning.
Hypokalemia with chronic use. Nursing Interventions: Assess patient for abdominal
distention, presence of bowel sounds, and usual pattern of bowel function. Assess color,
consistency, and amount of stool produced.

Morphine 4mg, IV, PRN Q4H. An opioid analgesic that binds to opiate receptors in the
CNS. Alters the perception of and response to painful stimuli while producing
generalized CNS depression. Side effects include CNS/respiratory depression,
constipation, sedation, confusion, and hypotension. Nursing interventions include: Assess
LOC, and Vitals (BP,P,RR) sedation throughout administration. RR<10 requires
intervention. Have antidote Naloxone (Narcan) 0.4mg IV on hand.

Roxanol (Morphine): 20mg/ml liquid suspension; Give 5mg/0.25ml dose PO every


four hours PRN for shortness of breath. Side effects: constipation, N,V. Nursing
Interventions: Assess LOC, and Vitals (BP,P,RR) sedation throughout administration.
RR<10 requires intervention. Have antidote Naloxone (Narcan) 0.4mg IV on hand.
Home medication:

Aspirin 81mg, One tablet taken Daily: See above.

Coumadin (Warfarin), 7.5mg PO QHS with INR goal of 2-3 seconds: See above.

6. Labs: give patient result and normal range; for abnormal results give possible reasons
for the abnormal results and how the abnormality might affect the patient.

WBC

Hgb

Hct

MCV

MCH

Laboratory Tests and/or Diagnostic Procedures:


CBC Profile: Significance of Test- This test is used to evaluate overall health.
A complete blood count (CBC) test measures the number of red blood cells (RBC count),
white blood cells (WBC count), amount of hemoglobin in the blood, and the fraction of
the blood composed of red blood cells (hematocrit). This test is used to evaluate overall
health. This test can also diagnose infections or allergies, detect blood clotting problems
or blood disorders, and evaluate red blood cell production or destruction (Kee, 2005, p.
718).
4/7
Units
St.
Abnorm Associated body systems, Functional health patterns, and
2015
Marks al or
Significance of Results
Ref.
Within
Range
Range
(RR)
18.1 K/uL
3.2-10.6 High
Immune System, Activity/Exercise/Health Management
Typically, when people have just had surgery or given birth,
are fighting any infection, bacterial or viral, WBC counts will
be elevated. However, the immune systems of people who
have chronic infection become exhausted and no longer have
the resources to produce and release mature WBC into
circulation. Band cells, or immature WBC will be introduced
into circulation in an effort to mount an appropriate immune
response. RO had CABG x 5 on 4/5/15, explaining his
elevated WBC count.
13.7 g/dL
11.6-16
Circulatory System, Activity/Exercise/Health Management
Within Hemoglobin reflects the amount of oxygen carrying capacity
Range on RBCs. Low values relate to fatigue and are influenced by
protein and iron consumption (Kee, 2005, p. 220).
42.4 %
34-46.8 Within Circulatory System, Activity/Exercise/Health Management
Range This is another test that measures amount of circulating RBC
(Kee, 2005, p. 217). This indicates that the ratio of volume of
red blood cells to the total volume of blood is not adequate.
Decreased levels of Hct can result in systemic decreased
oxygenation, hypoxemia, and hypoxia.
9.3
fL
6.1-9.7 Within Circulatory System, Activity/Exercise/Health Management
Range Mean corpuscular volume, or MCV, indicated the size of
circulating RBC and is a measure of the average red blood
cell volume/size (Kee, 2005, p. 380). Decreased MCV may
indicate iron deficiency anemia and thalassemia. Increased
MCV may indicate pernicious anemia and folic acid anemia
(Kee, 2005, p. 379).
29.9 Pg
25.1Within Circulatory System, Activity/Exercise/Health Management
34.6
Range MCH indicates the weight of hemoglobin on circulating RBC
regardless of size (Kee, 2005, p. 380).

MCHC

34.4

g/dL

33.435.3

Within
Range

Circulatory System, Activity/Exercise/Health Management


Indicates the actual HBG concentration (or oxygen carrying
capacity) of each RBC. Low values indicate decreased Hbg
on RBC and can indicate hypochromatic anemia, contributing
to hypoxia, hypoxemia, and fatigue (Kee, 2005, p. 380).

PLT

400

k/uL

140440

Within
Range

Circulatory System, Activity/Exercise/Health Management


Platelets assist in the clotting cascade and prevent profuse
bleeding (Kee, 2005, p. 264).

Blood Chemistry (Also known as CMP, BMP or CHEM-7): Significance of TestThis commonly performed blood test provides key information regarding fluid and
electrolyte status, kidney function, nutritional status, blood sugar levels, and response
to various medications and other medical therapies by assaying the circulating levels
of essential electrolytes, BUN, creatinine, and albumin (Kee, 2005, p.745).

4/7
2015

Units

Ref.
Ran
ge
74 106

Abnormal
or Within
Range
High

Glucose

133

mg/dL

Sodium

143

mmol/
L

136 - Within
145 Range

Potassium

4.5

mmol/
L

3.5 5.1

Within
Range

Calcium

7.6

mg/dL

8.2 10.3

Low

Associated body systems, Functional health patterns, and


Significance of Results
Endocrine System, Nutrition/Metabolic
Glucose levels are important as the reveal the amount of
sugar (energy) in the body. With a low glucose level, the
brain will not have adequate energy to function. A
consistently high glucose level may indicate diabetes. RO
elevated glucose levels could be related to medications and
hypermetabolic state r/t recent CABG x 5 surgery on
4/6/15.
Nervous & Muscular System, Activity/Exercise &
Nutrition: Sodium is a vital electrolyte, one that represents
hydration and dehydration status. Sodium levels help
reflect how the kidneys are functioning.
Nervous & Muscular System, Activity/Exercise &
Nutrition: Potassium is the main intracellular electrolyte
and is responsible for nerve conduction (Holland, et. al., p.
358, 2011). Cardiac arrest and/or dysrhythmias can occur if
serum levels are outside range (decreased and elevated).
Decreased level of potassium places RO at risk for heart
dysrhythmias (Lemone & Burke, 2011). Nurse will
monitor for symptoms of hypokalemia and dysrhythmias
(Silvestri, 2011). RO receives 40mg, PO, BID.
Nervous & Muscular System, Activity/Exercise &
Nutrition: Calcium is an important mineral for the function
of nerve impulses, muscle movement, heart function, and
teeth and bone strength. People with renal failure often
have disturbances in the metabolism of calcium and

CO2

31

mmol/
L

23 32

Within
Range

Creatinine

1.1

mg/dL

0.61.3

Within
Range

Urea
Nitrogen
(BUN)

13

mg/dL

7-18

Within
Range

EGFR

>60

>60 Within
<130 Range

pH

7.36

7.35- Within
7.45 Range

HCO3

26

1626

Within
Range

Traponin I

0.10

00.08

High

ng/mL

phosphorus, resulting in hyperparathyroid levels and


increased bone resorption. This cascade causes bone pain,
bone fractures, and muscle weakness. ROs decreased Ca
levels were reported to provider. RO experienced no heart
arrhythmias throughout shift. Average HR ~94 BP~118/84.
All Systems, Urinary, Respiratory, GI Systems, Activity/
Exercise & Nutrition:
CO2 levels shows how the patient's kidneys and lungs are
functioning. Changes in CO2 level may suggest losing or
retaining fluid, which causes an imbalance in the body's
electrolytes. Patient RO has CO2 levels within normal
limits.
Urinary System, Elimination:
Creatinine, like BUN, also reflects kidney functioning.
However, creatinine concentration depends on muscle
mass (instead of protein intake), and is considered a more
reliable index of renal failure. ROs creatinine is high
indicating his kidneys are functioning properly.
Urinary System, Elimination:
BUN is blood urea nitrogen. Urea is formed as an end
product of protein metabolism and is excreted by the
kidneys. An elevated blood urea nitrogen level could be an
indication of dehydration, prerenal failure, or renal failure.
Urinary System, Elimination:
GFR indicates the volume of blood in mL the kidneys are
able to filter through the glomeruli each minute. Normal
GRF is 60mL/min. GFR monitoring is a diagnostic test that
infers how well the kidneys are functioning (Lemone &
Burke, p. 769, 2011).
All Systems/ Circulatory System, Activity/Exercise/
Nutrition/Metabolic/Health Management:
Determines the acidity or alkalinity of body fluids, thus
effecting metabolism, oxygenation, and organ function
(Kee, 2005, p. 65).
All Systems, Urinary, Respiratory, Renal, GI Systems,
Activity/ Exercise & Nutrition:
Bicarbonate ion is alkaline however acts generally as a
buffer and maintains the acid base balance in the body and
maintaining pH within normal parameters (Kee, 2005, p.
65).
Circulatory System, Activity/Exercise/Nutrition/
Metabolic/Health Management:
Cardiac traponins indicate myocardial injuries r/t acute MI,
chest pain, and myocardial damage (Kee, 2005, p. 433).

Coagulation Profile Significance of Test: Coagulation tests are performed to determine how
long the clotting time is for patients blood (Kee, 2005, p.643). Many medications and
pathologies can effect clotting times. Depending of the pathologies a patient has been diagnosed
with will determine the coagulation time goal. RO requires anticoagulation therapy and currently
takes 5mg daily r/t his history of atrial fibrillation.
4/7
Ref Range Goal Abnormal Significance
2015
or Within
Range
PT

13.9

1013sec

INR

1.2

0.9-1.2sec

High

23sec

High

Prothrombin time is a measure of the amount of time


required for inactivated prothrombin to be converted into
thrombin and begin the clotting cascade. This test is
performed for clients who take oral anticoagulants like
warfarin/Coumadin (Kee, 2005, p. 371). This is an
important test to monitor for RO because he has been on
long-term anti-coagulation.
This test was developed to improve the monitoring
process of clients on long-term warfarin anticoagulant
therapy (Kee, 2005, p. 371). Monitoring PT and INR is
especially important given than Warfarin therapy.

II. Assessment of Gordons Functional Health Patterns


Health Perception Health Management
History and Physical:
RO is a married 61-year-old male of large frame and is slightly obese. RO is a pleasant
man who is quick to smile and joke. Over the past few years he has retired and volunteers his
time for the American Heart Association and American Red Cross. He considers himself healthy
but I need to lose about 50 pounds. RO has a history of well-controlled atrial fibrillation and
hyperlipidemia.
On April 5, 2015, RO presented to St. Marks Hospital via ambulance with complaints of
severe crushing chest pain after I ate a bowl of pasta. I had a quiet morning and was mostly
sitting around. Then after I ate this chest pain hit me like a ton of bricks. Ive never had that
before and it scared me. My wife was out running our dogs, so I called an ambulance (RO,
personal communication, April 7, 2015). RO has been diagnosed with coronary artery disease

(CAD) and on Monday April 6, 2015 had coronary artery bypass grafting x 5 with selective
coronary angiography and Left heart catheterization. Description of procedure includes: Left
internal mammary artery to bypass diagonal LAD. Saphenous vein to bypass distal circumflex &
OM. RO tolerated the surgery well without complications and was extubated without
complications. He is currently stable in his pain is well controlled. He is sleepy and not able to
concentrate or read my book, but my thoughts a clear, theyre just a little slow (RO, personal
communication, April 7, 2015).
Admission Vitals:

1330

36.2C

Site: Temporal

HR

92 RRR

RR

20

O2

97%

Significance:
ROs BP is uncharacteristically
elevated. His pain is severe.
Based on these subjective and objective
findings, a MI is suspected. EKG is
ordered. Review findings below.

Site: Right forefinger

BP

185/95

Site: Left arm; lying position

Pain

10

Assessment tool: Numeric scale 0-10

Admission EKG:
Ventricular rate
Atrial rate

1345
88
88

PR

186

QRS duration
QCT calculation
P axis
R axis
T wave axis

116
464
49
-42
71

Impression: Abnormal EKG


Left axis deviation
Normal Sinus Rhythm (NSR)
Non-specific ST abnormality

Family history:
Father: Dead- Heart disease
Mother: Alive- Arthritis and HTN
Brother: Alive- Hyperlipidemia, HTN, DM
Lifestyle:
Married for 40 years
45-year career as an electrician.
Currently retired.
Denies alcohol and recreational drug use
Never a smoker.
Prioritized Nursing Diagnoses related to Health Perception Health Management Pattern:

Ineffective protection (RO) r/t neuromuscular deficits, impaired mobility, risk for falls,
risk for impaired skin integrity, and anticoagulation drug therapies, more than nutritional
requirements, impaired circulation, insufficient cardiac output secondary to CAD,
NSTEMI and history of atrial fibrillation AEB weakness, immobility, CABAG x 5
surgery.

Risk for falls (RO) r/t medications (diuretics, statins), confusion, impaired sensory
perception, physical weakness, and impaired physical mobility.

Risk for injury (RO) r/t positioning during recent surgery, medications (diuretics,
statins), confusion, impaired sensory perception, physical weakness, and impaired
physical mobility.

Nutritional/Metabolic
Currently, while hospitalized RO is ordered a regular diet. He didnt have much of an
appetite but was compliant with encouragement to eat chicken broth, apple juice, and applesauce,
as well as drank adequate amount of water throughout my shift. During the day RO asked me if
he was going to be able to live a normal life, I mean is my heart so bad now? I encouraged him

to discuss everything we are talking about with his surgeon, but he has responded well to the
surgery, is doing excellent right now, and in my opinion has a good prognosis because he is
relatively healthy and has only a few risk factors including high cholesterol and is a little
overweight. I explained that while those risk factors are serious and contributed to his heart
condition, the good thing is that they could be addressed with some lifestyle changes including
exercise and diet. This put him at ease and he reported I need to lose more than a little weight,
but I am motivated to do what I need to do to be healthier. I told his it is hard to make changes
in his diet and to be more active, but with the right support it is manageable. RO responded, yes
it might be a little hard at first, but really I am lucky. Basically, I made myself sick and almost
died from it, and that is silly. My wife is so active and healthy; she could run up a mountain. I
think this may be a blessing because I can spend more time with my wife being active with her. I
am very lucky.
Prioritized Nursing Diagnoses related to Nutritional-Metabolic Pattern:

Risk for deficient fluid volume (RO) r/t decreased oral fluid intake, increased insensible
water loss from rapid respirations, potential hypermetabolic state and immune system
stimulation. AEB disinterest in eating and drinking, and occasional tachypnea.

Imbalanced nutrition: more than body requirements (RO) r/t intake of nutrients that
exceeds metabolic needs AEB obesity.

Risk for electrolyte imbalance (RO) r/t decreased oral fluid intake, increased insensible
water loss from rapid respirations, potentially hypermetabolic state and immune system
stimulation. AEB RO verbalizations I am not hungry, but Ill try to eat.

Risk for Impaired Skin/Tissue Integrity (RO) r/t surgical incisions, physical
immobilizations, and potential neurosensory deprivation.

Elimination
While hospitalized at St. Marks Hospital, ROs I&Os are being strictly documented. For
preparation for surgery, on 4/6/2015, an indwelling urinary catheter had been inserted. During
student nurses shift, RO drank 600mL of water, 120mL of apple juice and 180mL of chicken
broth. Urinary elimination 900mL. His last BM was 4/5/2014. Indwelling urinary catheter
removed 1000 w/o difficulties of complications. He was assisted to the bathroom when
necessary. Upon d/c of indwelling catheter, no voiding difficulties noted.
Prioritized Nursing Diagnoses related to Elimination Pattern:

Risk for constipation (RO) r/t immobilization, sedentary lifestyle, potential for
insufficient intake of required fluid volume, psychological stress associated with
hospitalization, CABG x 5 surgery, recent diagnosis of CAD, uncertainty of health
outcomes, strain on self-perception, possible depression, and polypharmacology.

Activity/Exercise
ROs current activity orders are minimum assistance. For most of the shift RO rested in
bed. He was very lethargic in the morning but by the afternoon came he was ready and eager to
walk. Physical therapy worked with RO twice (1230 and 1600) on 4/7/15. Once for bedside
range of motion activities and then took a walk around the unit in the later afternoon.
Around 1200, RO became more alert and talkative. I took this opportunity to interview
him and help him get cleaned up with a bed bath and oral care.
RO was receiving 4L supplemental oxygen via nasal cannula. He was able to maintain
oxygen saturations >93% throughout shift. I expect oxygen weaning will begin later on 4/7/15.
However, I anticipate he will wear his NC through the night while sleeping and true weaning of
supplemental oxygen will begin 4/8/15. See above lab value tables for arterial blood gas values.

Throughout shift vital signs and cardiac heart rhythm were continually monitored. At
beginning of shift, RO had chest tubes x 3 (one for each pleural space and one for pericardial
space), pacemaker wires, and arterial line. Chest tubes were d/ced at 1100 on 4/7/15 without
complications per provider order, however, there was a fair amount of resistance in removing the
chest tubes. My nurse and I asked for assistance from a senior nurse. Output was 500mL on 4/6
and 100mL on 4/7. RO was able to maintain normal sinus rhythm since emerging for surgery and
was not dependent on pacemaker wires. Pacemaker wires were d/ced without compilations at
1110 per provider order. Arterial line was located in right radial artery and d/ced at 1125 per
provider order. Pertinent hemodynamic monitoring values include: CVP (a measure of blood
volume and venous return. It reflects right-sided filling pressures. It is primarily used to monitor
fluid volume status. Normal value is 2-6 mmHg)= 5mmHg, CO (amount of blood in L heart
pumps per minute. This value is affected by body size. Assesses the hearts ability to meet the
bodys oxygen demands and heart function. Normal value 4-8 L/min)= 7L/min, CI (calculation
of cardiac output per square meter of body surface area. CI is a more precise measurement of
heart function. Normal value is 2.8-4.2 L/min/m2)= 4 L/min/m2, PAWP (measures pressures
generated by the left ventricle. It is used to assess left ventricular function. Normal value is 8-12
mmHg) = 10 mmHg, MAP (The average pressure in a patient's arteries during one cardiac cycle.
It is considered a better indicator of perfusion to vital organs than systolic blood pressure.
Normal value is 70-105mmHg) = 73 mmHg, SvO2 (Measures the end result of O2 consumption
and delivery. A measurement of oxygenation saturation from mixed venous blood (SvO2) in the
pulmonary artery. It can be used as a marker of how well O2 is being delivered to the peripheral
tissues Normal value is 65-70%) = 68%. See table below for alternative review of hemodynamic
monitoring information.

4/7/15

Units

Ref Range

CVP

mmHg

2-6 mmHg

CO

L/min

4-8 L/min

CI

L/min/m2

2.8-4.2
L/min/m2

PAWP

10

mmHg

8-12
mmHg

MAP

15

mmHg

70105mmHg

SvO2

68

65-70%

Abnormal Significance
or Within
Range
Within
A measure of blood volume and venous
Range
return. It reflects right-sided filling
pressures. It is primarily used to monitor
fluid volume status.
Within
Amount of blood in L heart pumps per
Range
minute. This value is affected by body size.
Assesses the hearts ability to meet the
bodys oxygen demands and heart
function.
Within
Calculation of cardiac output per square
Range
meter of body surface area. CI is a more
precise measurement of heart function.
Within
Measures pressures generated by the left
Range
ventricle. It is used to assess left
ventricular function.
Within
The average pressure in a patient's arteries
Range
during one cardiac cycle. It is considered a
better indicator of perfusion to vital organs
than systolic blood pressure.
Within
Measures the end result of O2 consumption
Range
and delivery. A measurement of
oxygenation saturation from mixed venous
blood (SvO2) in the pulmonary artery. It
can be used as a marker of how well O2 is
being delivered to the peripheral tissues.

After removal, we further consulted with the senior nurse. She advised us it is best
practice to always remove pacemaker wires first and then chest tubes. The reasoning behind this
is if there is internal bleeding incurred by removing the pacemaker wires, then the chest tubes
will be able to syphon off this extra fluid. She also confirmed with us that we understand not to
remove pacemaker wires if there is a fair amount of resistance, however resistance while
removing chest tubes is common.

Prioritized Nursing Diagnoses related to Activity-Exercise Pattern:

Decreased cardiac output (RO) r/t altered heart rate conduction (tachycardia) and
altered contractility of heart (atrial fibrillation), and altered afterload secondary to CAD,
hyperlipidemia, and NSTEMI. AEB tachycardia, history of atrial fibrillation, abnormal
EKG changes, reduction in ejection fraction (=27%), lesion on his mid Left Anterior
Descending coronary artery, Mid LAD: 10-20% stenosis, and LAD (overall): Luminal
irregularities.

Impaired physical mobility (RO) r/t sedentary lifestyle, activity intolerance, medications,
musculoskeletal impairments, and post surgical pain AEB limited range of motion, slow
movement, and verbalizations Im tired from that walk, it took a lot out of me, but Ive
got to start somewhere.

Activity Intolerance (RO) r/t recent CABG x 5 surgery, generalized weakness, sedentary
lifestyle, and immobility AEB verbalizations of tiredness and weakness.

Sleep/Rest
RO reports, Normally, at home I sleep pretty sound. I usually fall asleep quick and sleep
through the night. While Im sleepy here and drop off quick, I cant stay asleep cause there are
many interruptions. But then sometimes when I wake up I cant fall back asleep again because I
am worried about how my life will change and if I am going to get better of die (RO, personal
communication, April 7, 2015). ROs wife, FO reports, I usually sleep well, but Ive had a hard
time these last few days from worrying if RO is okay (FO, personal communication, April 7,
2015). In an effort to promote rest, throughout my shift I repositioned RO to comfort, dimmed
lighting when appropriate, and spoke with RO to address his health concerns. More than
anything I encouraged him that he is recovering well and in a good position to take control of his

health with some lifestyle modification that were well within his ability. He was receptive to
teaching and encouragement and stated he is motivated to do what I need to do (RO, personal
communication, April 7, 2015). I also advised him to follow up with his surgeon regarding the
information we discussed regarding his prognosis. RO stated, Im not a TV watcher and I cant
concentrate on my book (RO, personal communication, April 7, 2015). I encouraged FO to
remember to take time for herself and her 25-year-old son, NO. NO reported he is responding to
his fathers condition similar to his mother.
Prioritized Nursing Diagnoses related to Sleep-Rest Pattern:

Disturbed sleep pattern (RO) r/t unfamiliar sleep surroundings/environment, and


separation form partner, stress, constant worrying, AEB verbalizations of interrupted
sleep and difficulty falling asleep.

Disturbed sleep pattern (FO and NO) r/t stress, constant worrying, caregiver role strain
AEB verbalizations of interrupted sleep and difficulty falling asleep.

Cognitive/Perceptual
Throughout shift on 4/7/15, RO was alert and orientated. As covered before, he
was sleepy in the beginning of shift and would drop off into sleep while performing morning
assessment, however he was orientated to his person, place, time, and situation. Again, he
became less lethargic as the day progressed.
Also discussed above are conversations related to ROs lack of knowledge
concerning his condition and prognosis. When FO joined us in the afternoon, she shared many of
ROs concerns and knowledge deficits. RO and FO appear to be a loving couple who are
genuinely motivated to move forward and make the necessary lifestyle changes.

Prioritized Nursing Diagnoses related to Cognitive-Perceptual Pattern:

Deficient Knowledge (RO and FO) r/t ROs medical conditions and lack of
understanding healthy positive ways to address his risk factors/comorbidities AEB RO
and FOs verbalizations regarding lack of understanding of medical diagnosis, CABG x 5
surgery and prognosis.

Self-perception/Role Relationships
Developmental theorist Erik Erikson described development that occurs through the
lifespan beginning with birth and ending with late adulthood. The individual acquires skills at
each stage to make him/herself a positive member of society. Each stage builds upon the
completion of earlier stages. If a stage is not successfully completed, Erikson proposed that this
would cause problems for the individual in the future and decrease the likelihood they will be
able to successfully complete the proceeding stages. Successful completion of a stage would
increase the likelihood a person will develop and advance in a healthy and positive manner
(DAmico & Barbarito, 2007, p.49).
I believe that RO and FO are Generativity vs. Stagnation stage. They are both retired and
volunteer independently. RO appeared to be a calm and thoughtful man and FO is a friendly
woman who is quick to smile. They both care about their communities and being involved. RO is
a volunteer with American Heart Association and American Red Cross and FO volunteers for the
Humane society. They shared with me that they enjoy taking their dogs to the desert to run
nearly everyday. Please review Coping/Stress Management/Values/Belief Patterns for further
information regarding family dynamics.
Elisabeth Kbler-Ross in her 1969 book, On Death and Dying, outlined the five stages of
grief: denial, anger, bargaining, depression and acceptance (Wilkinson et. al., 2007, p.143). I do

not believe that RO or FO are experiencing complications of grieving. They accept his condition
and the lifestyle changes he must make if he is to maintain his health. I reviewed with them the
importance of them both having advanced directives. They both were eager to receive this
information and agreed they would discuss and make advanced directives for both of them with
the social worker prior to discharge. A request was sent via EPIC for a social worker to consult
RO.
Prioritized Nursing Diagnoses related to Self Perception/Self Concept/ Role-Relationship
Pattern:
Social Isolation (RO) r/t limited physical mobility, therapeutic isolation, cognitive
deficits AEB spending entire day in her room, inability to maintain physical activity,
difficulty in engaging in outings.

Fear (RO and FO) regarding ROs medical and cognitive condition r/t, little
understanding of ROs medical complexity regarding comorbidities, and uncertainty of
ROs health outcome.

Risk for Caregiver role strain (FO) r/t pt. ROs increasing care needs, uncertainty of
demands in caregiving, and uncertainty of RO health outcome.

Sexuality/Reproduction
RO is a 61-year-old male who has been married for 40 years to FO. This is a first
marriage for both. RO expressed to me they are happy and sexually activebut only with each
other. FO chucked and confirmed this. RO received a vasectomy over 15 years ago. They have
one 25-year-old son, NO and a 30-year-old daughter, BO (RO and FO personal communication,
April 7, 2015).

Prioritized Nursing Diagnoses related to Sexuality/Reproductive Pattern:

No deficits to diagnose.

Coping/Stress Management/Values/Belief Patterns


As mentioned above, RO is worried about his condition but receptive to teaching,
encouragement, and suggestions for lifestyle modification. Furthermore, he repeatedly expressed
motivation to make these changes. He receives great support from his wife and son. Currently,
his daughter lives in Oklahoma, but reports, we are a close family. We are very lucky and enjoy
each other (RO, FO, and NO, personal communication, April 7, 2015).
Prioritized Nursing Diagnoses related to Coping-Stress Tolerance/Values-Belief Patterns:

Risk for Compromised family coping r/t ROs declining health, comorbidities and
uncertainty of prognosis.

III. General head to toe assessment


Vital signs: For 4/7/2015
Orders:
Vital Signs Q15min.
T

0800

1200

1600

36.8C

36.7C

37.2C

HR

86 RRR

92 RRR

91 RRR

RR

20

20

20

O2

94%

94%

94%

107/56

103/55

105/62

Site: Temporal

Site: Right forefinger

BP
Site: Left arm; lying position

Pain
Assessment tool: Numeric scale 0-10

General Survey: 61 year old Caucasian male, well-developed with symmetric facial and body
structures. RO was alert, friendly, smiling, cooperative, and held eye contact throughout
assessment. Conversation appropriate for situation. Speaks with clear audible speech at an
appropriate volume.
Neurological: LOC x4 (orientated to person, place, time, situation). Sensory to soft and blunt
object UE/LE. Glasgow Coma Scale=15.
Head: No lumps, lesions, tenderness reported. Thin white hair distributed throughout scalp.
Facial movements and structures symmetric. No TMJ. Full neck ROM intact, strength 5/5. Sclera
white, conjunctiva clear with no redness or drainage. PERRLA, accommodation sluggish.
Corneal light reflex symmetric 1 oclock bilateral. No nystagmus and EOMs. Visualization of
thickened secretions in nares and throat.. Septum midline. Ears patent, finger rub test positive
bilateral, no redness or drainage bilateral. Dentition intact with no appliances. Buccal mucosa,
gums, and tongue pink and moist with no lesions or bleeding. Tongue midline and mobile. Uvula
rises with vocalization.
Skin: Color appropriate for ethnicity, skin warm and dry. Scant edema (+1) noted BLLE. Good
turgor with no tenting present bilateral UE/LE. Hands and legs dry, applied lotion. Nails clean,
short, pink with no clubbing bilateral UE/LE. Surgical incisions present on thorax. Midline
incision unable to assess covered with gauze with scant amount of dried blood present and
medipore. Mid-thoracic chest tubes x 3 placed 4/6/15 and d/ced 4/7/15. Incision sites covered
with Vaseline gauze, gauze, and covered with nonporous tape. Sites assess every hour
throughout shift. No drainage present. Mid-thoracic pacemaker wires x 2 sites placed 4/6/15 and
d/ced 4/7/15. Incision sites covered with gauze and covered with nonporous tape. Sites assess
every hour throughout shift. Scant amount of serosanguinous drainage present on right dressing
and reinforced once throughout shift. Left gauze indicated no drainage present.
Braden Pressure Risk Score: 8 (RO is low risk for developing pressure sores).
Pulmonary: Lungs clear to auscultation bilateral with diminished breath sounds noted in
bilateral lower lung fields. Supplemental oxygen at 4L via nasal canula. Oxygenation saturations
>90% throughout shift. CVA 90 degrees. Excursion noted. Uses IS independently and with
encouragement 10 breaths once every hour throughout shift achieving 1500mL.
Circulatory: S1 and S2 noted. No extra heart sounds. No bruits carotids/abdominal aorta. Radial
and dorsal pedal pulses 2+ RRR. Cap refill <3 sec bilateral LE/UE. Positive Allens test right
hand. Negative Homans sign bilateral.
Abdominal: Skin intact, color consistent. Abdomen round. No rebound, tenderness, pain, distention,
masses, guarding bruits. Active bowel sounds x4.
Musculoskeletal: Full ROM UE/LE bilateral. Reports feeling of general weakness in upper and
lower extremities bilaterally. Strength noted 5/5 UE/LE bilateral while lying in bed. RO. is able to
reposition effectively and gaining strength .

Morse Fall Risk: Assessment score 80 (RA is high risk for falls).
GI: No rectal problems reported. Last bowel movement 4/5/15. Stool firm, well-formed and
brown. No reports of nausea or vomiting.
GU. Skin intact, slightly moist sacral and scrotum. Denies dysuria. No difficulties voiding after
d/c of indwelling urinary catheter.
Diet: Regular diet. RO has decreased appetite but was able to eat drank 600mL of water, 120mL
of apple juice and 180mL of chicken broth. No reports of nausea or vomiting.
IV: 22 gauge peripheral IV in Right Antecubital inserted on 4/5/15. Insertion site clean and dry.
No redness or swelling noted. Dressing clean and dry. Transparent dressing placed over IV site and
dated. Patent; flushes easily IV line saline locked per hospital protocol. Arterial line inserted 4/6/15 to
right radial. Insertion site clean and dry. No redness or swelling noted. Dressing clean and dry.
Transparent dressing placed over IV site and dated. Line assessed, zeroed and monitoring device
alarms checked 0830. D/ced per provider orders 4/7/15 at 1125 with no complications. Right Internal
jugular device inserted 4/6/2015. Unable to assess site r/t gauze dressing. Lines were flushed, patent
and saline locked when not in use.
Drains: Indwelling urethral 16F foley catheter inserted 4/6/2015. Output 500mL for 4/7/15.
D/ced per provider orders 1110 4/7/15 with not complications, output 800mL. Perianal care
provided. Chest tubes x 3 (one for each pleural space and one for pericardial space). Chest tubes
were d/ced at 1100 on 4/7/15 without complications per provider order. Output was 500mL on
4/6 and 100mL on 4/7.
Immunization/Vaccinations: Pneumococcal Jan 10, 2015; Influenza- Jan 2015; Tetanus,
Diphtheria, Pertussis (Td/Tdap)- 2010.
Mobility/Assistive devices: Glasses and walks with wheelchair for stability and transport of
monitoring devices when ambulation with 1 person assist. Gait steady.
MMorholt, WCSN, 2/3/2015, 12:30.
IV. Prioritization of Nursing Diagnoses:
1) Decreased cardiac output (RO) r/t altered heart rate conduction (tachycardia) and altered
contractility of heart (atrial fibrillation), and altered afterload secondary to CAD, hyperlipidemia,
and NSTEMI. AEB tachycardia, history of atrial fibrillation, abnormal EKG changes, reduction
in ejection fraction (=27%), lesion on his mid Left Anterior Descending coronary artery, Mid
LAD: 10-20% stenosis, and LAD (overall): Luminal irregularities.

2) Ineffective protection (RO) r/t neuromuscular deficits, impaired mobility, risk for falls, risk
for impaired skin integrity, and anticoagulation drug therapies, more than nutritional
requirements, impaired circulation, insufficient cardiac output secondary to CAD, NSTEMI and
history of atrial fibrillation AEB weakness, immobility, CABAG x 5 surgery.
3) Deficient Knowledge (RO and FO) r/t ROs medical conditions and lack of understanding
healthy positive ways to address his risk factors/comorbidities AEB RO and FOs verbalizations
regarding lack of understanding of medical diagnosis, CABG x 5 surgery and prognosis.
4) Activity Intolerance (RO) r/t recent CABG x 5 surgery, generalized weakness, sedentary
lifestyle, and immobility AEB verbalizations of tiredness and weakness.
5) Fear (RO and FO) regarding ROs medical and cognitive condition r/t, little understanding
of ROs medical complexity regarding comorbidities, and uncertainty of ROs health outcome.
The above list of prioritized nursing diagnoses were chosen based on the level of threat
posed to the life and wellness of patient RO and his significant others as well as considering
Maslows hierarchy of needs and addressing a wide array of Gordons functional health patterns.
Furthermore, the majority of prioritized nursing diagnoses, and their care plans, have the quality
of encompassing a multitude of nursing diagnosis that subscribes to nearly all of Gordons
functional health patterns. Identifying nursing diagnosis that cover the entire spectrum of issues
presented to RO and his significant others (SOs) assures comprehensive quality nursing care,
that is focused on remedying and preventing problems, will be provided. I believe the tertiary,
quaternary, quinary nursing diagnosis are significantly important and influential to the quality of
life for RO and his family and friends. If RO does not fully understand how to appropriately
manage is comorbidities and successfully make appropriate lifestyle changes current and longterm quality of life, health, and wellness, significant negative repercussions may be experienced

by everyone. However, adherence to guidelines of prioritization of nursing care plans defined by


NANDA, in accordance with the rules of ABC (airway, breathing, and circulation), as well as
Maslows hierarchy of needs, other nursing diagnoses must take precedence.
Decreased cardiac output (RO) has been identified as the priority nursing diagnosis
because using the rules of ABC prioritizing as well as urgent-nonurgent prioritizing, ROs recent
NSTEMI and necessity for CABG x 5 surgery is potentially life-threatening.
Ineffective protection (RO) has been identified as the secondary nursing diagnosis
because it is a full spectrum diagnosis, one that addresses nearly all of Gordons functional
health patterns and a multitude of nursing diagnosis that have been identified to pertain to RO
(see above description of diagnosiss related to as well as entire list of identified nursing
diagnosis). The nursing care plan that applies to this nursing diagnosis addresses all levels of
Maslows hierarchy of needs and offers quality care that addresses current issues, enables nurse a
better chance of identifying potential problems, and consequentially places nurse, caregiver, and
patient in best position to help prevent problems.
Deficient Knowledge (RO and FO) has been identified as the tertiary nursing diagnosis.
In my short time with RO and his family, we had multiple conversations r/t his medical condition
and prognosis. I observed no barriers to learning and believe that RO is motivated and has
sufficient support for loved ones to assist him in successfully achieving his learning and lifestyle
goals.
Activity Intolerance (RO) has been identified as the quaternary nursing diagnosis because
if he is unable to regain strength he will become discouraged and unable to make appropriate
lifestyle changes. Furthermore, he may become unable to independently perform ADLs and
subsequently increased his wifes caregiver role strain. I believe RO will make a progress in

regaining his strength and have a good recovery. In the short time I worked with him I witnessed
him regaining strength and activity tolerance AEB his afternoon walk.
Fear (RO and FO) regarding ROs medical and cognitive condition has been identified as
the quaternary nursing diagnosis because if they are unable to fully achieve and understanding of
his condition and if he is unable to decrease his activity intolerance, they may resort to constant
worrying and fear. This would not be advantageous because increased stress, worrying, fear, and
continual excitement of the sympathetic nervous system releases cortisol, epinephrine, and
adrenaline, placing RO at risk for repeated MI.
V. Care Plan:
(2) Decreased cardiac output r/t altered heart rate conduction (tachycardia) and altered

contractility of heart (atrial fibrillation), and altered afterload secondary to CAD, hyperlipidemia,
and NSTEMI. AEB tachycardia, history of atrial fibrillation, abnormal EKG changes, reduction
in ejection fraction (=27%), lesion on his mid Left Anterior Descending coronary artery, Mid
LAD: 10-20% stenosis, and LAD (overall): Luminal irregularities.
Intervention: At
Rationale:
Evaluation:
beginning of shift,
Complies with providers orders.
At beginning of shift I checked
nurse will assure
Continuous EKG monitoring assures safety of RO by
monitors, lead placements, and
arterial line and
providing timely acknowledgement of cardiac function confirmed audible volumes for
continuous cardiac
changes and promoting likelihood of corrective
alarms. Arterial line was d/ced
monitor is operating
measure to be implemented at first sign of cardiac
per provider order at 1200.
effectively by zeroing
deficit (Doenges et. al., 2008, p. 159).
Confirmation of continuous
arterial line, checking
monitoring was reassessed.
monitors, lead
placements, and
assuring volumes are
audible.
Intervention:
Nurse will monitor
ROs labs (e.g. CBC,
electrolytes/BMP,
BUN/Cr, ABGs, and
cardiac marker) daily.

Rationale:
Outlines existing and potential problems (Kee, 2005,
p.640). Allows incite for ROs condition and health
status that will dictate nursing care and required
frequency of assessing RO for deficits and changes in
health status (e.g., oxygenation/respiration, LOC,
cardiac function)

Evaluation:
Before beginning of providing
care, at beginning of shift, I
reviewed ROs previous labs. I
then reviewed labs drawn that day
(4/7/2015) when they were
released by lab around 1000.

Intervention:
Nurse will assess and
monitor for changes in
VS, LOC, and signs of
PE and cardiac
failure/shock every
hour.
Nurse will also educate
RO and FO how to
assess and monitor
changes in ROs status,
focusing on acute chest
pain, dyspnea,
cyanosis, anxiety, and
restlessness.

Rationale:
Assessment is the first step in the nursing process and
provides the foundation and rationalization for all
nursing interventions/actions (Wilkinson et. al., 2007,
p. 39). Noting any changes in respiratory status in a
timely manner as quickly as possible increases the
chances problems will be identified early (Doenges et.
al., 2008, p.158) and addressed in the appropriately
prioritized order (Wilkinson et. al., 2007, p. 66).

Evaluation:
Throughout shift I monitored and
assessed for changes in LOC, and
signs of PE and cardiac
failure/shock every hour. VS
were assessed as per providers
orders Q4H.

Intervention:
Nurse will monitor
cardiac rhythm
throughout shift.

Rationale:
To assess effectiveness of cardiac medications
(Doenges et. al., 2008, p.158).

Intervention:
Nurse will administer
oxygen by using
appropriate method to
maintain oxygen
saturations >90%.
Intervention:
Nurse will position RO
in semi-Fowler to highFowlers position
throughout shift and
encourage him to sit in
a chair as often as
possible.
Nurse will place RO in
Supine or
Trendeledburgs
position (legs higher
than head) when
evidence for
cardiogenic shock is
present.
Nurse will teach these

Rationale:
Maintaining adequate oxygenation is essential healing
and to preventing further health complications
(Lemone & Burke, 2011, p.289). Increases O2
available for cardiac function and tissue perfusion
(Doenges et. al., 2008, p. 158).
Rationale:
Semi-Fowler to high-Fowlers position decreases
oxygen consumption, oxygen demand (Doenges et. al.,
2008, p. 158). Respiration effort is decreased and
oxygenation is increased in this position (Lemone &
Burke, 2011, p. 1237). Trendeledburgs position is the
appropriate position for clients experiencing shock to
be placed (Lemone & Burke, 2011, p. 264). ROs
condition requires extensive education and teaching to
be provided to RO and FO. Their successful transition
from hospitalization to being discharged to home
depends on how well they understand RO medical
condition and his comorbidities pathologies, what the
prescribed tx are, the rationale/importance of the tx,
and how to perform/administer the tx (Lemone &
Burke, 2011, p. 45).

Evaluation:
Throughout shift I monitored
ROs cardiac rhythm and noted
effectiveness of cardiac
medications (note changes in VS
from 0800 to 1200BP
decreased but HR increased)
Evaluation:
Throughout shift I monitored and
assessed ROs oxygenation
saturation. Supplemental oxygen
was required throughout shift at
4L via nasal cannula.
Evaluation:
Throughout shift I assured RO
was in semi-Fowler to highFowlers position and was able to
assist in ambulating him to sit in
bedside chair after
encouragement.

positions, when to
employ them, and
rationale to RO and
FO.
Intervention:
Nurse will encourage
ambulation (within his
limits) of RO.

Rationale:
Ambulation and exercise supports heart health
(Wilkinson et. al., 2007, p. 904).
Ambulation and exercise addresses many of ROs
goals including being discharged safely from the
hospital, regaining musculoskeletal strength, reducing
risk for impaired skin integrity by being mobile,
increasing circulation and oxygenation, maintaining his
health, avoiding emergent health situations, losing
weight, and reconnecting with his wife via integrating a
more active lifestyle together.

Outcomes:
RO will demonstrate cardiac
and hemodynamic stability
(stable BP, cardiac output,
renal perfusion, urinary output,
peripheral pulses) during
hospitalization and after
discharge.
Outcomes:
RO and FO will verbalize to
nurse by end of shift signs of
cardiac failure and shock.

Outcomes:
RO will demonstrate an
increase in activity tolerance
by discharge and after
discharge.

Evaluation:
I was able to assist in ambulating
RO to bedside chair twice during
shift. RO participated willingly
with physical therapist twice
throughout shiftonce for
bedside exercises, and once by
walking and completing 2 laps
around the ICU ward.

Evaluation
Short-term goal: Achieved During my shift,
RO demonstrated cardiac and hemodynamic
stability. I was able to assess stable BP, urinary
output and peripheral pulses.

Evaluation
Long term goal:
Achieved when RO is able to
continue to demonstrate cardiac
and hemodynamic stability after
discharge.

Evaluation
Short-term goal: Achieved
RO and FO verbalized to me the signs of
cardiac failure and shock (dyspnea, syncope,
orthostatic hypotension, peripheral edema) as
well as measures to be taken in such and event
(sit down, rest, seek help/report to/call 911)
Evaluation
Short-term goal: Achieved
In the one shift I worked with RO as his student
nurse, he has been able to ambulate while using
a wheelchair for stability while maintaining
adequate cardiac function and oxygenation.

Evaluation
Long term goal:
N/A

Evaluation
Long term goal:
Achieved when RO continues to
make steady progress after he is
discharged home.

References
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