Nursing Care Plan

Patient Name: A.R.C. Age: 81 years old Sex: Male Civil Status: Married

Medical Diagnosis: Cardiovascular Disease Atrial Fibrillation in Cardiovascular

Resistance Hypertension Stage 1

Attending Physician: Dr. Jacob Singh M.D.

I. Chief Complaint/ Other Complaints

Left sided weakness of the extremities

Frontal headache and Dizziness

II. Nursing History

1 day PTA, the client was walking in their living room area in the

afternoon when he felt a sudden weakness of his left side extremities

followed by frontal headache and dizziness. There were no associated

signs and symptoms of nausea, vomiting, tinnitus and blurring of vision.

The client did not take any medications and disregarded the symptoms he

felt. Few hours prior to admission all the symptoms he felt worsens and he

was been brought to De Lasalle University Medical Center Dasmariñas

Cavite hence admitted. The patient had history of hypertension for 20

years. He had no asthma or allergies. According to the client he cannot

recall his grandparents and parents cause of death and his other siblings.

III. Pathophysiology

Modifiable FactorsSmoking

Hypertension

Non-Modifiable Factors

AgeGender

Familial History

Uncontrolled prolong blood pressure

altered cellular structure and metabolism, inhomogeneity of the myocardium, poor perfusion, myocardial fibrosis,

and fluctuation in afterload

increased risk of ventricular tachyarrhythmias

left atrial structural abnormalities, associated coronary artery disease, and Left Ventricular

Hypertrophy

development of atrial fibrillation

decompensation of systolic and, more importantly, diastolic dysfunction, owing

to loss of atrial kick

Cardiovascular Disease Atrial Fibrillation in Cardiovascular

Resistance Hypertension Stage 1

AnginaPalpitation

HypertensionDizziness

Weakness of body parts

CBCLipid profile

Serology

IV. Laboratory/ Diagnostic Result, Interpretation and Nursing ImplicationProcedure /

Date and Time Indication Normal Values / Findings Actual FindingsNursing Responsibilities /

Implications (Pre, Intra, Post)

Complete Blood Count

This test is used to determine the levels of various components of the blood to determine abnormalities. This test can detect the presence of anemia and oxygenation status, as well as presence of infection.

Hemoglobin

Hematocrit

Segmenters

Lymphocytes

Monocytes

M: 127 – 183 g/L

0.37 – 0.54

0.50 – 0.70

0.20 – 0.40

0.00 – 0.07

140 (NORMAL)

0.42 (NORMAL)

0.50 (NORMAL)

0.08 (LOW)

0.02 (NORMAL)

Before the procedure: > Check for physician’s orders.> Confirm the identity of the client for sample extraction.> Inform the patient and his family of the procedure and its purpose to allay anxiety.> Inform the patient and his family that laboratory personnel will come to the ward for the extraction of blood sample.

During the procedure:> Provide support for the client.

After the procedure:> Document the procedure on the patient’s chart.> Document the patient’s response and tolerance to the procedure.> Assess the venipuncture

Serology

Clinical laboratory test to measure blood serum level.Serum Creatinine- Used to detect renal damage.

Sodium- Measures water-balance, acid-base balance of the body

Potassium- Measures amount of potassium in the body.

Serum Creatinine

Sodium

Potassium

58 – 110 mmol/L

137 - 145 mmol/L

3.50 – 5.10 mmol/L

110.00 (NORMAL)

142.00 (NORMAL)

3.10 (LOW)

site for bleeding or hematoma formation.> Inform the physician of the results.> Inform the client and his family that the physician will explain the results of the procedure and its implications on his condition.

Pre: Tell the patient’s

relative that the test requires a blood sample. Explain who will perform the venipuncture and when.

Explain to the patient’s relative that the patient may experience slight discomfort from the needle puncture and the tourniquet.

Intra: Ensure sub-dermal

bleeding has stopped before removing pressure.

Post:

Analysis:

The results showed in hematology that there is a low amount of lymphocytes. Low lymphocyte count may be due to the presence of infection. In serology test, decreased levels of potassium indicate hypokalemia. Decreased levels may occur in a number of conditions, particularly: dehydration, vomiting, diarrhea.

If a hematoma develops at the venipuncture site, apply warm soaks.

V. Medications and Treatment

Brand Name/ Generic Name

Dosage/ Frequency/ Route

Indications/ Contraindications

Side Effects and Adverse Reactions

Nursing Responsibilities

Amlodipine (Norvasc)

5mg 1 tab BID PO

I: Chest pain or heart pain (angina) occurs because of insufficient oxygen delivered to the heart muscles. Amlodipine is also used in the treatment of high blood pressure.CI: Hypersensitivity to drug.

Side effects of amlodipine are generally mild and reversible. The two most common side effects are headache and edema (swelling) of the lower extremities. Less common side effects include dizziness, flushing, fatigue, nausea, and palpitations.

Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels ofamlodipine are achieved 6–9 h following oral doses.

Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied byweight gain; rarely, severe edema may cause discontinuation of drug.

Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added.

Monitor heart rate; dose-related palpitations (more common in women) may occur.

Patient & Family Education Report significant

swelling of face or extremities.

Rosuvastatin (Crestor)

Lactulose

Citicholine (Zynapse)

20 mg 1 tab ODHS

30 cc BID

1 gm tab BID

I: Rosuvastatin is used for the reduction of blood total cholesterol, HDL cholesterol and triglyceride levels, and to increase HDL cholesterol levels.CI: Hypersensitivity to drug, patients with liver disease.

I: ConstipationCI: Patient who require low lactose diet.

I: Head injury, Cerebrovascular diseaseCI: Parasympathetic hypertonia

The most common side effects of rosuvastatin are headache,nausea, vomiting, diarrhea and muscle pain. The most serious side effects are liver failure, muscle breakdown (rhabdomyolysis) and kidney failure.

Bloating symptom, diarrhea, epigastric pain, flatulence, nausea and vomiting

Body temperature elevationRestlessnessHeadachesNausea and vomitingDiarrheaLow or high blood pressureTachycardiaSleeping troubles or

Take care to have support when standing & walking due to possible dose-related light-headedness/dizziness.

Report shortness of breath, palpitations, irregular heartbeat, nausea, or constipation to physician.

Do not breast feed while taking this drug without consulting physician.

PRE:-Check the doctor’s order.-Observe the 10 rights of drug administration.-Ask patient’s family if he is allergic to any drugs.-Monitor vital signs every 4 hours.-Prepare the drug using aseptic technique.-Ensure that the client has eaten his meal.

INTRA:-Administer as ordered.-Monitor the client’s response and tolerance during drug administration.

POST:-Monitor vital signs.-Instruct client to

insomniaBlurred visionChest pains

consult health care provider if rash, diarrhea or digestive problems occur. -Inform the client to avoid performing potentially dangerous activities due to dizziness. -Document the administration of drug on the client’s chart.-Document the patient’s response and tolerance to the procedure.-Practice aseptic technique by washing hands and disposing materials appropriately in the designated waste bin.

VI. Nursing Priorities

A. ACTUAL or Active

Problem No. Problem Date Identified

1 Ineffective tissue

perfusion

May 9, 2011

2 Activity Intolerance May 9, 2011

VII. Nursing Care Plan

CUES NURSING DIAGNOSIS

LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

S> “Medyo

nahihilo ako,

parang umiikot

ang paligid.”

O> VS taken as

follows: T=36.1

PR= 60 RR= 24

BP= 150/80

(-) chest pain

(+) dizziness

(+) irregular beat

of pulse

(+) nausea and

vomiting

(-)loss of appetite

(-) edema

Ineffective tissue perfusion r/t compromised blood flow secondary to hypertension.

Within 1 week intervention, the patient will be able to maintain BP within acceptable range.

The patient will be able to maintain BP within individually acceptable range within the 8 hour shift.

INDEPENDENT: ♦ Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain. ♦ Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol.♦Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. ♦ Suggest frequent position changes, leg exercises when lying down.

Help patient identify sources of

Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. ♦ These risk factors have been shown to contribute to hypertension. ♦ Lack of cooperation is common reason for failure of antihypertensive therapy. ♦ Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting

Goal Met. The patient was able to maintain BB w/in individually acceptable range.

sodium intake. ♦ Encourage patient to decrease or eliminate caffeine like in tea, coffee, cola and chocolates. ♦ Stress importance of accomplishing daily rest periods. COLLABORATIVE: Provide information regarding community resources, and support patients in making lifestyle changes.

or standing. ♦ Two years on moderate low salt diet may be sufficient to control mild hypertension. ♦ Caffeine is a cardiac stimulant and may adversely affect cardiac function. ♦ Alternating rest and activity increases tolerance to activity progression. ♦ Community resources like health centers programs and check ups are helpful in controlling hypertension.

CUES NURSING DIAGNOSIS

LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

S> “Parang

nanghihina ang

kaliwa kong part

ng katawan.”

O> (+)

weakness of left

side extremities

(-) shortness of

breath

(-) pallor

(+) irregular

pulse rate

BP= 150/80

RR= 24 cpm

Activity

intolerance r/t

weakness of left

side body part.

The patient will be able to report a measurable increase in activity intolerance w/in 1 week intervention.

The patient will be able to participate in desired activities like dressing within 8 hr shift.

Asses the client’s response to activity, noting pulse rate more than 20 beats/ min or faster than resting rate; marked increase in BP during activity.

Instruct client in energy-conserving techniques e.g. using the chair when showering, ambulating slowly.

Encourage progressive activity/ self-care when tolerated. Provided assistance as needed.

The stated parameters are helpful in assessing physiologic responses to the stress of activity and indicators of overexertion.

Energy saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

Gradual activity progression prevents a sudden increase in cardiac workload.

Goal met. The patient was able to participate in desired activities like dressing within 8 hour shift.

Synthesis:Cardiac arrhythmias commonly observed in patients with hypertension include atrial fibrillation, premature ventricular contractions (PVCs), andventricular tachycardia (VT).

The risk of sudden cardiac death is increased. Various mechanisms thought to play a part in the pathogenesis of arrhythmias include altered cellular structure and metabolism, inhomogeneity of the myocardium, poor perfusion, myocardial fibrosis, and fluctuation in afterload. All of these may lead to an increased risk of ventricular tachyarrhythmias.

Atrial fibrillation (paroxysmal, chronic recurrent, or chronic persistent) is observed frequently in patients with hypertension. In fact, elevated BP is the most common cause of atrial fibrillation in the Western hemisphere. In one study, nearly 50% of patients with atrial fibrillation had hypertension. Although the exact etiology is not known, left atrial structural abnormalities, associated coronary artery disease, and LVH have been suggested as possible contributing factors. The development of atrial fibrillation can cause decompensation of systolic and, more importantly, diastolic dysfunction, owing to loss of atrial kick, and it also increases the risk of thromboembolic complications, most notably stroke.

Premature ventricular contractions, ventricular arrhythmias, and sudden cardiac death are observed more often in patients with LVH than in those without LVH. The etiology of these arrhythmias is thought to be concomitant coronary artery disease and myocardial fibrosis.

VIII. Discharge Plan

Content Strategy1. Compliance

Medication

Diet

Exercise Activity/Lifestyle

- Instruct the client and his family to take all medications as prescribed.

- Advise the client to avoid using non-prescription drug unless use is approved by the physician.

- Encourage the client to take medications exactly as prescribed by the physician.

- Instruct the client to eat high protein foods, foods rich in Vitamin C, Vitamin D, and Calcium. Instruct client to increase oral fluid intake unless contraindicated.

- Maintain good hygiene for the client, especially on the surgical site.

- Provide periods of rest and avoid strenuous activities.

- Perform leg exercises as ordered.

- Health teachings

2. Follow up/ Check-up

- Instruct the client’s family on following the check-up schedule given by the physician.

- Health teachings

Signature over Printed Name