HA NOI MEDICAL UNIVERSITY

ADVANCED NURSING PROGRAM

NURSING CARE PLAN

STUDENT : PHẠM THU QUỲNH

GROUP : 41 CLASS: Y4Q

UNIT : C2- Viet Nam national heart institute- Bach Mai Hospital

DATE OF CARE : 17/12/2018 (5th day after admission)

PATIENT’S FULL NAME : Bui Van Hoan

BED: 15 UNIT: C2

ADMISSION DATE: 13/12/2018

AGE/GENDER : 58/ Female

ALLERGIES : no allergies

SOCIAL SUPPORT: Tran Thi Thi

Phone number: 01663853392

ADDRESS : Thuy Nguyen-Hai Phong

Reason for hospitalization:

shortness of breath and edema

Medical diagnosis:

atrial fibrillation – heart failure, pneumonia

Present history:

Before admission 3 months ago, he appeared short of breath, edema whold

the body. He went to distric hospital to treatment a lot of times. Edema was
decreased , he still had dyspnea and he was trasferred to Viet Nam national
heart institute of Bach Mai Hospital on December 13,2018.

Medical history:

a. Patient history

Atrial fibrillation – heart failure EF 27%

COPD 1 year, regular treatment.

b. Family history

No metabolic disorder has been found.

Focus assessment:

1. Admission condition(22/11/2018)

- alert, G=15 point

- dyspnea NYHA 3 , increased breathing difficulty when exertion

- Chronic cough that produce sputum white

- facial edema

- no fever

- pink skin and mucosa

- no hemorrhage under the skin, no tumor, no ulcer

- Normal lung sounds, no rales.

- no hepatomegaly

- Vital signs: Pulse: 70pbm

 BP:160/100mmHg

RR:22 pbm

Temperature: 37oC

SpO2=96%

2. Current assessments (17/12/2018)

a. general conditions:

- alert, G=15 point

- fatigue (weakness, limited range of motion)

- cough with sputum white

- dyspnea NYHA 2

- mild facial edema

- pink mucous and membrane

- no hemorrhage under the skin

- no fever

- no tumor, no ulcer

- Vital signs: Pulse: 90pbm

BP:140/80mmHg

RR:22 pbm

Temperature: 36.8oC

- Weight: 58 kg Height: 1.58 m

BMI= 23.2 (normal)

b. Cardiovacular system

- Heart rate: 90bpm.

 - Blood pressure: BP: 140/80mmHg

- pink pale skin,mucous membrane.

- Capillary refill: <2s

c. Respiratory system:

- Respiratory rate: 22 bpm,

- short of breath, NYHA 3 (follow a downward trend)

- increased breathing difficulty when exertion

- crackle sound

d. Gastrointestinal system

- Abdomen: symmetric, no tumor, no scar.

- Soft, no acsites

- Eating by mouth, no vomiting

- stool: yellow, normal

e. Musculoskeletal system

normal

f. Genitourinary system

no has abnormal

Laboratory test

LABORATORY REFERENCE Result

RATIONALE/EXPLANATION
TEST VALUE
(ABNORMAL VALUES ONLY)
RANGES
WBC (21/8/2018) 4.0 – 10.0 Gl 13.25
Neutrophils % 45 – 75% 85.2
Lymphocytes % 25 – 45% 10.6
Monocytes % 0 – 8% 3.4
Eosinophils % 0 – 8% 0.4
Basophils % 0 – 1% 0.4
Neutrophils # 1.8 – 7.5G/l 11.3
Lymphocytes # 1.0 – 4.5G/l 1.4
Monocytes # 0 – 0.8G/l 0,45
Eosinophils # 0 – 0.8G/l 0,05
Basophils # 0 – 0.1G/l 0,05
RBC 4.5-5.9 T/l 4.44

HGB 135 – 157g/l 143

HCT 0.4-0.53 l/l 0.42

MCV 80 – 100Fl 95.3

MCH 26 – 34pg 32.2
MCHC 315 – 363g/l 338
Platelets 150 – 400G/l 185
Basic
Metabolic
Panel:
Na 133-147 mmol/l 134
K 3.4 – 4.5 mmol/l 4.0
Cl 94 – 111 mmol/l 95
Ure 3.2-7.4 mmol/l 6.8
Creatinine 59-104 µmol/l 94
Glucose 4.0-6.0 mmol/l 5.6
AST <37 U/L 42 Assesment of liver
 function

ALT <41 U/L 71

CK 38-147 U/L 72
CK-MB <24 U/L 27
CRP <0.5 mg/dL 0.645 Risk of infection

Coagulation: ‘

(13/12)
Prothombin S 29.6
PT % 70 – 140 % 32
PT-INR 2.08
Immune: (13/12)

Troponin T =<14 ng/L 18.31 Risk of recurrence of

atrial fibrillation
NT-proBNP < 14.47 pmol/L 945.3 heart failure in patients
with dyspnea

Urine test

Urine test REFERENCE Result

VALUE
(14/12)
RANGES

LEU (-) (-)

PRO (-) (-)

SG 1.003-1.030 1.012

GLU (-) (-)

NIT (-) NEG

PH 5.5-6.5 6

KET (-) (-)

UBG 3.2-16 umol/L 3.2

 ERY (-) (-)

BIL (-) (-)

A/C normal norma

OTHER DIAGNOSTICS OR SIGNIFICANT INFORMATION (x-rays, MRI, other

studies):

-ECG:

Atrial fibrillation

Left ventricular wall thickness

- Doppler ultrasound: (13/12)

The left ventricular wall thickness, function of left ventricular systolic is

decreased

(EF 44%)

Mild cleft mitral valve

- Coronary Angiography Report :

narrow leision 80% LAD, 60% Lcx, 40% RCA

-X-ray:

blurred spots scattered on ½ of the right lung

NURSING PROCESS

date of care: 17/12/21018

5th day after admission

Diagnosis 1: ineffective breathing pattern related to heart failure and

COPD

Nursing intervention Rational

1. Inspect thorax for symmetry of 1. Determines adequacy of breathing
respiratory movement
2. Observe breathing pattern: nasal
flaring, pursed-lip breathing or
prolonged expiratory phase and use of
accessory muscles
3. Assess emotional response
2. Identifies increased work of
breathing
3. Detects use of hyperventilation as a
causative factor
4. To have a maximum lung expansion

4. Place patient in semi-fowlers

position

Descride outcome:

 improve breathing pattern

 maintain a respiratory rate within normal limits.

Diagnosis 2: Decreased Cardiac Output related to decreased function of

the heart

Nursing intervention rational

1. Auscultate apical pulse, assess heart 1. Tachycardia is usually present (even
rate, rhythm. Document dysrhythmia if at rest) to compensate for decreased
telemetry is available ventricular contractility

2. Palpate peripheral pulses 2. Decreased cardiac output may be

reflected in diminished radial,
3. Monitor BP popliteal, dorsalis pedis, and post tibial
pulses
4. Inspect skin for pallor, cyanosis
3. the body may no longer be able to
5. Monitor urine output, noting
compensate, and profound
decreasing output and concentrated
hypotension may occur.
urine
4. Pallor is indicative of diminished
6. Encourage rest, semirecumbent in
peripheral perfusion secondary to
bed or chair. Assist with physical care
as indicated
7. Administer medications as
indicated: Diuretics( furosemide),
Digoxin
Describe outcome:
 decreased episodes of dyspnea, angina
 reduce cardiac workload.
diagnosis 3: Fatigue related to condition disease
Nursing intervention
1. Assess vital signs
2. Obtain client descriptions of fatigue
3. Ask client to rate fatigue
4. Assess the patient’s ability to
perform ADLs, instrumental activities
of daily living (IADLs), and demands
of daily living (DDLs).
5. limiting strenuous activity,
Establish realistic activity goals with
client and encourage forward
movement
6. Make the patient aware about the
inadequate cardiac output,
vasoconstriction, and anemia
5. Kidneys respond to reduced cardiac
output by retaining water and sodium
6. improve efficiency of cardiac
contraction and to decrease myocardial
oxygen demand/ consumption and
workload.
rational
1. To evaluate fluid status and
cardiopulmonary response to activity
2. To assist in evaluating impact on
client’s life
3. To determine degree of fatigability
4. Fatigue can restrict the patient’s
ability to participate in self-care and do
his or her role responsibilities in the
family and society, such as working
outside the home.
6. Changes in heart rate, oxygen
saturation, and respiratory rate will
reflect the patient’s tolerance for
signs and symptoms of overexertion activity.
with activity.

Describe outcome:

 Patient will report improved sense of energy

Diagnosis 4: risk of deep venous thrombosis, presure ulcer related to

reduce mobility

Nursing intervention rational

1. Assist with frequent changes of 1. Turning and ambulation enhance
position, and encourage ambulation as aeration of different lung segments,
tolerated thereby improving oxygenation

2. Turn and position the patient every 2. Reduces pressure on tissues,

2 hours or as needed. improving circulation and reducing
time any one area is deprived of full
3. When patient is on bed rest, the feet blood flow.
and lower legs should be elevated
periodically above the level of the 4. Exercise enhances increased venous
heart, and active and passive leg return, prevents stiffness, and
exercises should be performed to maintains muscle strength and stamina
increase venous flow
5. Skin is at risk because of impaired
4. Execute passive or active assistive peripheral circulation, physical
ROM exercises to all extremities immobility, and alterations in
nutritional status.
5. Inspect skin, noting skeletal
prominences, presence of edema, areas 6. Excessive dryness or moisture
of altered circulation, or obesity and/or damages skin and hastens breakdown.
emanciation
6. Provide frequent skin care:
minimize contact with moisture and
excretions
Describe outcome:
 no appear deep venous thrombosis
 ho have ulcer
Diagnosis 5: defition knowledge
Nursing intervention
1. Discuss normal heart function.
Include information regarding patient’s
variance from normal function.
Explain difference between HF
2. Discuss importance of being as
active as possible without becoming
exhausted and of rest between
activities
3. Review medications, purpose, and
side effects. Provide both oral and
written instructions
4. Recommend taking diuretic early in
morning
5. Explain and discuss patient’s role in
control of risk factors (smoking,
unhealthy diet) and precipitating or
aggravating factors
rational
1. Knowledge of disease process and
expectations can facilitate adherence to
prescribed treatment regimen
2. Excessive physical activity or
overexertion can further weaken the
heart, exacerbating failure, and
necessitates adjustment of exercise
program
3. nderstanding therapeutic needs and
importance of prompt reporting of side
effects can prevent occurrence of drug-
related complications
4. Provides adequate time for drug
effect before bedtime to prevent
interruption of sleep.
6. Eating more salt increases water
retention, affecting heart failure, fat
causes strong atherosclerosis
6. Nutrition education: limit salt and
sodium-rich foods, enhance fiber-rich
foods, limit fat and food vapor

Describe outcome:

 Identify relationship of treatment therapies to reduction of recurrent

episodes and prevention of complications

Medicine

Name of drug Dose and Effects of drugs Side effects of drugs

route
administration

Lovenox 2 pump anticoagulant Bleeding, bruising,

40mg/0.4 ml local / body allergy,
Subcutaneous
thrombocytopenia, skin
injection
rash, elevated liver
8:00-20:00 enzymes

Furosemid 1 tubes - a diuretic effect - Digestive disorders

20mg/2ml
IV -Pulmonary - Electrolyte
edema, liver, disturbances,
8:00
kidney or other hyperuricemia
origin, pulmonary
- visual disturbances,
edema, cerebral
tinnitus, transient
edema, pertussis,
hearing loss, muscle
mild to moderate
spasm, loss of
hypertension
 sensation, postural

-hypotension,
pancreatitis, liver
damage and increased
light sensitivity

Kalium 2 tablet - electrolyte

chloratum 50mg supplement - hyperkalemia
Oral

Drink in the
morning
Zetril 5mg 1 tablet - unexplained - Dizziness, headache,
hypertension and hypotension, cough,
Oral diarrhea, nausea,
hypertension due
kidney dysfunction
Drink in the to renal vascular
morning disease

- Support for
treatment with
diuretics

Digoxin Richter 1/2 tablet - treating heart - Tachycardia, slow or

0.25mg failure, atrial irregular
Oral
fibrillation,
-Blood or black stool,
Drink in the
-maintaining tar;
morning
normal heart rate,
-Blurred vision, golden
stabilizing
look;

-Confusion, illusion,
thinking or unusual
behavior
Vincerol 4mg ¼ tablet - Treatment and - Bleeding, drug
prevention of allergy, rash, anorexia,
 Oral deep venous diarrhea, skin necrosis,
thrombosis, jaundice, liver
Drink in the
pulmonary dysfunction, nausea,
evening
embolism, acute vomiting and
myocardial pancreatitis
infarction
Vitamin 1 tablet - helps maintain - hypersensitive
B1+B6+B12 physical activity,
Oral
-blood production
Drink in the -supports energy
morning metabolism

Crestor 10mg 1 tablet - Lower

cholesterol and
Oral
triglyceride (fat)
Drink in the in the blood and
evening after slow down the
eating build up of plaque
(fat in the blood)