Mr. SB, 60-year-old male is a retiree and was admitted to the hospital accompanied by his daughter. He is 100kg at a height of 180 cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, patient was complained of shortness of breath for 2 weeks and was worsening on the day of admission. Besides, he also experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea and leg swelling up to his thigh. Mr. SB was admitted to the hospital for to the same problem last year.
Mr. SB had known case of heart failure since 3 years ago and he had also diagnosed with hypertension for 5 years. Before admitted to the hospital, patient was taking furosemide 40mg, aspirin 150mg, metoprolol 50mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. Patient is not allergic to any medication and he does not take any traditional medicines at home. His family history revealed that his father had died of ischemic heart disease 4 years ago while his brother has hypertension. As for his social history, he smokes 2-3 cigarettes a day for 35 years and the calculated smoking pack years was 5 pack years. Besides, Mr. SB also drinks occasionally.
On examination, Mr. SB was found to be alert and conscious, but he was having pedal edema up to his knee. Besides, the patient was noted with bi-basal crepitations with no rhonchi. His body temperature was normal. However, his blood pressure was found to be elevated upon admission with a record of 159/100 mmHg with an irregular pulse rate at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while chest X-ray was conducted and revealed that the patient had cardiomegaly.
Lab investigations such as full blood count, liver function test, urea and electrolyte test and cardiac enzyme were done upon admission. His creatinine concentration was found to be 143µmol/L. Therefore, the calculated creatinine clearance was 68.8ml/min. Besides, there was also blood found in the urine and the echocardiography showed that the patient has sinus tachycardia. In addition, ECG test was performed on day 1 and the result indicated that there was a T-wave inversion. The patient’s INR was 1.04 which was lower than normal while APTT was found to be slightly higher (59.4 seconds). Mr. SB’s random blood glucose was found to be normal during his hospitalization.
Mr. SB was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient also suffered from hypertension. The management plan included intravenous furosemide 40mg twice daily, aspirin 150mg once daily, simvastatin 40mg once at night and Ramipril 2.5mg once a day. Besides, patient was asked to restrict his fluid intake to 500ml per day and oxygen therapy was given to patient at high flow using a face mask when patient experiencing shortness of breath.
As for his clinical progression, on day 1, the patient was complained of shortness of breath, leg swelling and orthopnea. Echocardiogram showed that he had cardiomegaly. Treatment of CHF was given. Throughout the stay in the hospital, Mr. SB had responded well to the heart failure therapy as there was no more complaint of chest pain or shortness of breath on day 13 and his pedal edema had gradually improved. However, patient’s blood pressure throughout day 1 to 9 was fluctuating between the range of 102/67-160/100 mmHg and therefore, hypertension treatment was given and blood pressure on day 10 onwards had been seen fell within the normal range. Furthermore, Mr. SB’s renal function became progressively worse from 143µmol/L on admission to 175µmol/L on day 11 and the calculated creatinine clearance on day 11 was 56.2ml/min.
Please create a care plan for this patient. Requirements for this care plan
1. You need to identify 5 nursing diagnosis that are pertinent for this patient (1st priority etc)
2. You need to expand on only one of those nursing diagnoses (meaning you needs to tell me the nursing diagnosis, place 10 interventions for that diagnosis, rationale)
3. Stimulate short term goals and long -goals for that diagnosis
4. What labs do you need to assess for this patient? Why
5. Pathophysiology of the disease
6. What nursing assessment should be performed at this time for this patient?
7. What is going on with Mr. SB?
8. Medications (make sure you incorporate them into the care plan)
9. What is your teaching plan?
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