Truckee Meadows Community College

Nursing Care Plan: Data Collection For The Hospitalized Client

(Use for preparation for clinical care, receiving & giving report.)

Room# 354 Client’s Init LGK Age 57 Sex Male Dates of care 9/4/07 and 9/5/07
Admit Date 8/30/07 Race/Ethnicity Japanese Spiritual Orientation None noted

Allergies NKDA Code Status Full

Admitting Dr. Rand Consulting Dr(s) Patin, Schenk, Reddy,

Primary Diagnosis (include surgery with date): Pulmonary embolism; lung cancer with brain metasis

SecondaryDiagnoses hypokalemia

Family History (parents, grandparents and siblings): No family history noted.

General Statement about current course of hospitalization Patient was diagnosed 10/2006 with
adenocarcinoma of the lung with metastases to the brain. He has undergone chemotherapy and radiation. Lately
he has been feeling ill with a hacking cough. Was seen in ER earlier in the month with pleural and pericardial
effusions. His more recent signs and symptoms include hacking cough, SOB, anorexia, bilateral pedal edema 2+
pitting, Caradiac tamponade, EKG sinus tachycardia, Pulmonary emboli in the lingual and L. lower lobe. Lung
sounds decreased at bases and R. middle lobe; expiratory wheezes. He has an increased risk for CVA due to
Coumadin and brain cancer. Patient has had 2 blood transfusions on 9/2 thawed plasma at 19:26 302mL and
22:23 288mL patient is A positive blood type.
Thoracentisis scheduled to be performed when INR levels are 1.65. Hold Coumadin and give more fresh frozen
plasma to decrease INR. Patient seems to be depressed, confused at times. Xanax seems to help. Bed alarm on.
Consider talking to Circle of Life. Patient has 2+ pitting pedal edema bilaterally that needs to be addressed. IV
site needs to be rotated.

Vital signs: baseline and recent V.S., frequency taken, hemodynamics (if measured). Vital signs Q4H; Vitals
on admittance P 109 R 22 BP 110/80 T 98.4 Ht. 66 inches wt 135lbs. Vitals 9/2 Wt. 143.20 P 61 R 22 BP
128/84 T 97.2 P 77 R 20 BP 115/83 T 97.2 P 105 R 22 BP 107/73 T 97 P 88 R 22 BP 115/89 T 97.2 9/3 P 87
R 20 BP 133/106 T 97.6 O2 sats 98% 4Lnc Wt. 145.30

Nutrition: PO- Diet ordered, NPO, tube feeding (type/size/location of tube, and strength/rate of administration
of feeding, amount of residuals), nutritional status (ht, wt, albumin level). Regular diet; Ht. 66in. Wt. 135lbs.
Albumin 2.7 on admittance. 9/2 Wt. 143.20lbs. 9/3 Wt. 145.30lbs.

Falls Assessment: Psychoactive medications, cognitive impairment, incontinence, unsteady gait, age 65 or
older, lower extremity weakness, prior fall within 24 hrs, seizure disorder, or sensory deficits. Patient is a high
fall risk due to unsteady gait and weakness.

Activity level: Assistive devices, number of persons required for activity, special type of bed.
9/4 bed alarm in place. Patient needs help ambulating. Will sit up in bed for periods of time. SOB with any
increased activity.

Intake/Output: PO, IV, urine (foley, voided, nephrostomy, intermittent cath), stool (LBM), emesis, wound
drainage, surgical drains, chest tube, tube feedings. Include previous 24 hr. total I & O and daily weights.
Intake 9/2 Oral 250 IV 1200 Piggyback 165 total 1615. Last BM 9/2
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IV’s: Type (peripheral, intermittent, central, hemodynamic monitoring, PICC), size, location, date inserted,
tubing and dressing change dates (Due when?), solutions and rate of infusing. IV NS TKO #20 Left FA 8/31
9/4 IV due to be changed.

Treatments: Resp-Oxygen, O2 sats, IS, NPPB (include medication used), Therapeutics- (OT, PT,
Communication), Wound care and dressing changes (frequently and method), capillary blood sugars (time
obtained, values, insulin coverage, when to inform DR.), Suctioning (oral/nasopharangeal/tracheal, frequency
and results), Tubes/Drains- tracheostomy (type & size), oral or nasal endotracheal tubes ( size and type),
nasogastric/orogastric/gastric/jejeunostomy tubes, chest tubes (site, drainage, amount of suction), ICP drains
Traction (location, type, weight applied), Continuous EKG (rhythm, rate, and ectopy), ,Ventilator settings
(mode, client and machine rate, FI02, tidal volume, use of PEEP or PS). Other Treatments:
Spirometer Q2HR; Chest physio therapy QID; NPPB QID and PRN Xopenex For Chest Pain: if spb>90 give
nitroglycerine 0.4mg SL. If pain continues, do ECG repear nitroglycerine 0.4 mg SL X2 prn. Or do stat ECG if
SBP >90 give nitroglycerin 0.4mg SL Q5 min X3 for continued pain Call Dr. for ECG changes or unrelieved
chest pain. Transfuse 3 units fresh frozen plasma.

Lab: Abnormals & Pending labs- pertinent with date, and pending labs (to be drawn while client receiving
your care, includes all lab tests performed Mon, Tues, and Wed during the week of care). Note trends in values
(changes from admit/preop/ previous levels)
9/3 Thoracentesis Pleural tap therapeutic and diagnostic specific gravity pleural fluid, cytology, gram stain and
C&S if indicated pH, glucose level, INR Qam 9/4 Thoracentesis rescheduled until INR down to 1.65. 9/4 CBC
CMP in a.m.

Other diagnostics: CT, MRI, X-ray, swallowing evaluation, ERCP, colonoscopy, gastroscopy, endoscopy,
ultrasound, angiogram, etc.
8/29 Cat Scan PE study with contrasts chest thorax with contrast; Portable chest one view

Case management/discharge plan (Consider collaborative practice: Communication therapy, Occupational

therapy, Physical therapy, Spiritual Care, Home health referral, Clinical specialists, Physicians, Social services,
Nutrition services, Rehabilitation) Patient likely to be discharged home with home health referral likely along
with continued routine visits to regular doctor. Consideration should be given to circle of life referral.

Teaching needs and plan: (Consider formal and informal teaching needs). Patient and family should be taught
signs and symptoms of CVA, respiratory distress, venous occlusion. Along with regard to anticoagulant
therapy. 9/4 Patient should be taught ways to increase breathing and oxygenation along with comfort levels.

Support systems for client: (Consider quality of interactions of significant others with client).
Patient seems to have a strong family support system. His wife and daughter are active in his care.

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 PHYSICAL ASSESSMENT DATA:

Physiological Variable

Assessment Data to Include: First Day of Care

SENSORY/PERCEPTUAL:
Mental status, Vision/ appearance of eyes,
Hearing, Touch, Taste & Smell,
Pain- location, description,
pain scale, Communication.
NEUROLOGICAL:
Pupillary Reactions, Orientation
Level of Consciousness, Grasp Strength, Reflexes
RESPIRATORY:
Rate, character, effort. Breath sounds
(include location),
Cough (describe
CARDIOVASCULAR:
Heart sounds – X 4 – S S2.
J.V.D., Pulses (rate, quality, rhythm):
Apical, radial, carotid, femoral, brachial,
posterior tibial, and dorsalis pedis.
Blood Pressure (arm used), Systemic/ peripheral
circulation (mucus membranes, capillary refill),
Homan’s Sign (bilateral)
SKIN:
Condition (color, turgor, character), Lesions, Edema,
Hair distribution, Incisions/IV site, Dressings,
Dehydration/edema, Temperature
MUSCULOSKELETAL:
Muscle tone & strength, Gait, stability.
Range of motion, Activity Level
GASTROINTESTINAL:
Mouth, gums, teeth, tongue (color and condition),
Gag reflex, Bowel sounds and last BM,
Presence of distention, impaction, hemorrhoids (external
GENITOURINARY:
Presence of retention, Discharge (vaginal, urethral),
Uterine response (pregnancy, postpartum),
Urine output (amount, description)

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 PHYSICAL ASSESSMENT DATA:

Physiological Variable

Assessment Data to Include: Second Day of Care

SENSORY/PERCEPTUAL:
Mental status, Vision/ appearance of eyes,
Hearing, Touch, Taste & Smell,
Pain- location, description,
pain scale, Communication.

NEUROLOGICAL:
Pupillary Reactions, Orientation
Level of Consciousness, Grasp Strength, Reflexes

RESPIRATORY:
Rate, character, effort. Breath sounds
(include location),
Cough (describe)

CARDIOVASCULAR:
Heart sounds – X 4 – S S2.
J.V.D., Pulses (rate, quality, rhythm):
Apical, radial, carotid, femoral, brachial,
posterior tibial, and dorsalis pedis.
Blood Pressure (arm used), Systemic/ peripheral
circulation (mucus membranes, capillary refill),
Homan’s Sign (bilateral)

SKIN:
Condition (color, turgor, character), Lesions, Edema,
Hair distribution, Incisions/IV site, Dressings,
Dehydration/edema, Temperature

MUSCULOSKELETAL:
Muscle tone & strength, Gait, stability.
Range of motion, Activity Level

GASTROINTESTINAL:
Mouth, gums, teeth, tongue (color and condition),
Gag reflex, Bowel sounds and last BM,
Presence of distention, impaction, hemorrhoids (external)

GENITOURINARY:
Presence of retention, Discharge (vaginal, urethral),
Uterine response (pregnancy, postpartum),
Urine output (amount, description)

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 DEVELOPMENTAL:

Client’s Life Stage (According to Erik Erickson):_______________________________________________________________

Expected Life Stage (for client’s age):________________________________________________________________________

Actual Stage (ID stage client is in during this hospitalization):_____________________________________________________

NORMAL FINDINGS (EXPECTED STAGE) CLIENT DATA

Biological

Psychological

Social

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 TRUCKEE MEADOWS COMMUNITY COLLEGE

WORKSHEET TO DETERMINE CLIENT STRESSORS

STEP 1) TALK TO CLIENT (while providing care): What is the most difficult part of dealing with your current situation? What

things are causing you the most concern or distress?

Ask further questions, if you need more information or clarification…

Disrupted your daily life? Similar problems in past?

Future consequences of this condition?

What are your expectations of caregivers, family, friends?

Identify Psychological strengths (ex. strong self-esteem) ____________________________________________

Psychological stressors (fears, insecurities)________________________________________________

Identify Sociocultural strengths (strong family bonds) _______________________________________________

Sociocultural stressors (cultural beliefs conflict with caregivers) __________________________________

Identify Spiritual strengths (beliefs, faith, hope) ______________________________________________________

Spiritual weaknesses (lack of faith/beliefs) ___________________________________________________

STEP 2) EXAMINE YOUR RESPONSE & PERCEPTIONS: Student’s perceptions or emotional response? Inconsistencies, or

missing information?

STEP 3) IDENTIFY & PRIORITIZE STRESSORS: A. As perceived by your client; then

B. As perceived by YOU, the nurse.

USE THIS INFORMATION TO COMPLETE STRESSORS SHEET ( DATA p. 6 )

INTRAPERSONAL STRESSORS- within the client, such as fear, anxiery, body image, pain

INTERPERSONAL STRESSORS- between the client & other individuals, such as conflict/disagreement with physicians, nurses,

family/significant others.

EXTRAPERSONAL STRESSORS- broader, more global stressors, such as employment, financial, insurance, or environmental

problems.

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 TRUCKEE MEADOWS COMMUNITY COLLEGE

STRESSORS AND SUMMARY

PRIORITIZED STRESSORS AS PERCEIVED BY CLIENT: TYPE OF STRESSOR (Intra, Inter, Extrapersonal

1.

2.

3.

4.

PRIORITIZED STRESSORS AS PERCEIVED BY NURSE:

1.

2.

3.

4.

SUMMARY OF ALL CLIENT DATA

Discuss the general status of the client in terms of the following: Identify the client’s strengths & weaknesses,
related to all of the 5 variables. (Review all data collected & “Stressors worksheet”.) Describe the internal and
external resources available to the client to achieve optimal wellness. Examine this data, then write a statement
about the client’s potential for reconstitution.

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 Truckee Meadows Community College
CLIENT INTERVIEW FORM

Information To Be Used For Nursing Care Plan (Pre-hospital ONLY)

So that I can provide you with the highest quality of care, I need to gather a variety of information about you. As

with all information gathered by your health care professionals, the answers you give me today are strictly confidential.

This information will be used to design a plan of care specifically for you and will address your unique needs. While you

are here at the hospital/clinic, in addition to treating your current illness / condition, we will also be discussing ways for

you to stay healthy and become even healthier.

Directions to Student Nurse: Circle or highlight areas of concern, as well as those which indicate the need for health
education. Also, mark client’s strengths (+) and weaknesses (-).

DEMOGRAPHIC INFORMATION

Date_____________ Client’s Initials_________________ Sex _________ Age_____________

Informant – Client Y / N Interviewed by_____________________________________,SN

*********************************************************
Chief Complaint(s):

History of Present Illness/Condition:

Past Medical History:

Family History:

*********************************************************
PHYSIOLOGICAL:
Health Promotion and Maintenance : General health good?

Number of colds/illnesses over the past year? Use cigarettes, alcohol, drugs?

What do you do to stay healthy? Are your efforts effective?

Are you usually able to follow the nurse’s/doctor’s advice?

Monthly Breast Self-Exam/Testicular Exam? Y / N

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Food & Fluid Intake-
Usual daily fluid intake- (Number of 8oz. cups/glasses) _________
Number of daily cups of coffee or caffeinated beverages _________

Usual daily food intake (Describe)

Weight gain/loss? ________ lb. within past yr.

Describe your appetite.

Skin problems, sores, dryness? Excess odor/ perspiration?

Usually heal well? Discomfort eating/chewing?

Dental problems? Last dental exam?

Urination & Bowel Movements-

Pattern of Urination (Voiding) # of BM’s daily? Time?

# of voids during the day? Diarrhea/ Constipation- now/ in the past?

Discomfort/ Burning/ Odor? Recent change in pattern/ appearance of BM’s?

Elimination aids? (Laxatives, Enemas, etc.)

Exercise, Leisure Time & Daily Activities-

Adequate energy levels? Leisure activities? Describe

Type & Amount (hrs or minutes) of Weekly Exercise?

In running your household (cooking, cleaning, etc), are there any activities that you require assistance with?
Yes/No __________. *(If answer Yes, fill in functional levels below)

In caring for your personal needs (Feeding, grooming, toileting, etc.), are there any things you require assistance
with? Yes/No____________. * (If Yes, fill in functional levels below)
FUNCTIONAL LEVEL (as perceived by client): Level 0- Full self-care; Lev. 2- Client requires equipment/device;
Lev. 3- Requires assist/supervision of 1 person; Lev. 4- Reqires 1 person & eequip./device; Level 5- Fully
dependent/ does not participate. Indicate level for the following:

Feeding _____ Grooming _____ Bathing _____ Toileting _____ Bed Mobility _____ Dressing _____ Cooking
_____ Shopping ______ Home Maintenance ______ Other ______
Sensory & Learning-

Recent change in your hearing? Wear an aid? Vision changes? Glasses/contact lenses?

Last eye exam? Changes in memory? Learning difficulties?

Easiest way for you to learn something?

Pain/discomfort? Describe it & tell how you manage it.

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Rest & Sleep-
Average number of hrs. of sleep per night? Use sleep aids/ describe?
Dreams/ nightmares?

Usually awaken & feel rested & ready for the day’s activities? Yes/No

Problems falling asleep, or awakening early?

PSYCHOLOGICAL:

Self-Concept-
Describe yourself. __________________________________________________________________________

Usually, do you feel good/ not so good about yourself? ___________________________________________

Has this illness/ condition changed how you feel about yourself or your body?________________________

Any body changes? ________________________________________________________________________

How do you feel about changes within or to your body? __________________________________________

Emotions, Coping & Stress-

Are you frequently angry? _____ Annoyed? _____ Fearful? _____ Anxious? _____ Depressed?________

What helps? ______________________________________________________________________________

Feel stressed or tense a lot of the time? _________ What helps? ____________________________________

Use alcohol, medications, drugs? (If yes, amount) _______________________________________________

Who gives you the most support in your life?___________________________________________________

How do they help? ______________________________Are they available to you now? ________________

Major changes in your life over the past year or two? ____________________________________________

How do you usually cope with stress or a major crisis? _________ Is this usually successful? Explain

What things have helped you to cope in the past? ________________________________________________

Sexuality-
FEMALE: Start of menstruation (periods)? ___________ Date of last menstrual period? _____________

Menstrual problems? _________ Para (live births)? ________ Gravida (pregnancies)? _____________

MALES & FEMALES:

Consistently use: Birth control? _________ Disease protection? Condoms/ Condoms with foam? _______

Problems with birth control or disease protection? ______________________________________________

Sexual relations with: Males? _____ Females? _______ Both? _________Abstain? ____________

Any recent changes in sexual relations? _____________ Any sexually-related concerns or questions?
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 SOCIOCULTURAL:

Culture & Relationships-

Member of a cultural or ethnic group? Describe ________________________________________________

If yes, does this group add (circle choices): Support? Conflict? Guidance? Stress? Satisfaction? Pride?

Live alone? With friends/ family/ significant other? _____________________________________________

Living situation or extended family adding stress or problems? ____________________________________

How does your family usually handle problems?_________________________________________________

Family depend on you? Yes/No How are you managing? _________ Family/ others reaction to condition?

Problems with children? Yes/No How are these going? ________________________________________

Belong to social groups? ______________ Have close friends? ________________ Feel lonely? Frequency

Your occupation? ___________________ Low/ moderate/ high stress? ____________

Things generally go well at work? ____________________ Income sufficient for your needs? __________

Feel a part of, or isolated in your neighborhood? _______________________________________________

SPIRITUALITY:

Values & Beliefs-

Usually do you get what you want out of life? ____________

What is (are) the most important thing(s) in life? ________________________________________________

Religious preference? _____________ Is it an important part of your life?__________________________

Helpful in both good & bad times? _______________

Will your condition/ treatment interfere or conflict with any religious preferences?

How can we help you better express or get-in-touch with your spiritual-self or beliefs?

Do you have any of the following? Living Will? Advanced Directive/Durable Power-of-Attorney? Organ Donor
Card?

OTHER: Is there anything else you want to talk about? ________________________________________

Do you have any questions? __________________________________________________________________

THANK YOU!! GRACIAS!! MERCI!! DANKE!! THANK YOU!! GRACIAS!! MERCI!!

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 DRUG INFORMATION SHEET
(Must complete sheets on ALL drugs prescribed for client while hospitalized,
include IV’s and O2)

GENERIC NAME: TRADE NAME(S):

CLASSIFICATION: (also include subclass or Pharm class, ie; Antihypertensive- Calcium channel
blocker

MECHANISM OF ACTION:

CLINICAL INDICATION/DESIRED EFFECTS:

CONTRAINDICATION(S):

COMMON ADVERSE EFFECTS:

REASON FOR CLIENT RECEIVING THIS DRUG:

CLIENT DOSE AND ROUTE:

SAFE DOSAGE RANGE: (for this route)

IS THIS SAFE?
NURSING IMPLICATION (include pertinent assessment, interventions/teaching):

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 DRUG INFORMATION SHEET
(Must complete sheets on ALL drugs prescribed for client while hospitalized,
include IV’s and O2)

GENERIC NAME: TRADE NAME(S):

CLASSIFICATION: (also include subclass or Pharm class, ie; Antihypertensive- Calcium channel
blocker

MECHANISM OF ACTION:

CLINICAL INDICATION/DESIRED EFFECTS:

CONTRAINDICATION(S):

COMMON ADVERSE EFFECTS:

REASON FOR CLIENT RECEIVING THIS DRUG:

CLIENT DOSE AND ROUTE:

SAFE DOSAGE RANGE: (for this route)

IS THIS SAFE?
NURSING IMPLICATION (include pertinent assessment, interventions/teaching):

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 DRUG INFORMATION SHEET
(Must complete sheets on ALL drugs prescribed for client while hospitalized,
include IV’s and O2)

GENERIC NAME: TRADE NAME(S):

CLASSIFICATION: (also include subclass or Pharm class, ie; Antihypertensive- Calcium channel
blocker

MECHANISM OF ACTION:

CLINICAL INDICATION/DESIRED EFFECTS:

CONTRAINDICATION(S):

COMMON ADVERSE EFFECTS:

REASON FOR CLIENT RECEIVING THIS DRUG:

CLIENT DOSE AND ROUTE:

SAFE DOSAGE RANGE: (for this route)

IS THIS SAFE?
NURSING IMPLICATION (include pertinent assessment, interventions/teaching):

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 LABORATORY VALUES, CHEMISTRY PANEL, ETC.
CHEMISTRY Normal Client’s Data & DATES of test INTERPRETATION OF ABNORMAL
PANEL Values 8/30 9/3 9/4 9/5 (cont. on back PRN)
SODIUM 136 – 145 137 138
POTASSIUM 3.5 – 5.0 3.2 4.4
CALCIUM 9.0 – 10.5 8.3 8.1 L Vitamin D deficiency
MAGNESIUM 1.3 – 2.1
Phosphorous 3.0 – 4.5
CHLORIDE 98 – 106 102 106
CO2 23 – 30 27 25
TOT.BILIRUBIN 0.3 – 1.0 1.1
DIR.BILIRUBIN 0.1 – 0.3
IND.BILIRUBIN 0.2 – 0.8
ALK PHOS 30 – 120 94
LDH TOTAL 100 – 190
Asp. Aminotrans- 0 –35 23
AST (SGOT)
Alanine 4 – 36 42
transferase
ALT (SGPT)
BUN 10 – 20 22 12
CREAT 0.6 – 1.2 1.2 0.9
(0.5-1.1 F)
URIC ACID 4..0– 8.5
(2.7-7.3 F)
TOT.PROTEIN 6.4 – 8.3 5.8 L Anorexia cancer
ALBUMIN 3.5 – 5.0 2.7 L Anorexia; cancer
GLOBULIN 2.3 – 3.4 3.1
A/G RATION > 1.0 0.9
GLUCOSE 70 – 105 130 161 Dexamethasone
(Fasting)
CHOLESTEROL <200
TRIGLYCERID 40 – 160
ES (Fasting) (35-135 F)
APTT 30 – 40 sec 21.1L
PT /INR 11- 12.5 11.4 PT 33.7 INR Cancer; Protonix increases INR
(no anticoags.)
0.9-1.1 2.73
LIPASE 1-160 U/L
AMYLASE 60-120su/dL

URINALYSIS Normal Values Client Data & DATES INTERPRETATION OF

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 ABNORMALS (Cont. on back PRN)
COLOR Pale yellow to
amber
APPEARANCE Clear
PH 4.6-8.0
Specific Gravity 1.005-1.030
Protein 0-8 mg/dL
Sugar Neg
Ketone Neg
Nitrates-Leukocyte esterase Neg
Microscopic Sediment Neg
Crystals
Crystals Neg
Casts Neg
WBC’S <4
RBC’s <2
*HOSPITAL LAB VALUES MAY DIFFER!

CBC NORMAL VALUES CLIENT’S with DATE INTERPRETATION OF ABNORMALS

8/30 9/4 9/5
WBC 5.0 – 10.0 13.4H Infrection stress inflammation
RBC 4.7-619 (F-4.2-5.4) 4.46 L pulmonary
Hgb 14-18 (F 12-16) 15.3
Hct 42 – 52 (F 37-47) 44.4
MCV 80-95 99.6 H Anemia B12 deficiency
MCH 27 – 31 34.3H anemia
MCHC 32 – 36 34.5
RDW 11.5-14.5 15.6
Platelets 150,000-400,000 221
MPV 7.4 – 10.4 7.4
WBC Differential
Polys (Neut’s) 55-70 74.9H stress
Stabs (Bands) 0-4
Lymp 20 – 40 17.0L Drug therapy
Mono 2-8 6.3
Eson 1-4 1.4
Baso .5-1.0 0.5
Macrocytosis 1+

BNP 52

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 DIAGNOSTIC PROCEDURES & LABORATORY VALUES

Test & Standard Data Client Results/ Medical Interpretation Student’s Interpretations & Nursing
Implications of Abnormals

8/29 Cat Scan PE study with contrasts 1. Acute lingular lobar and left lower lobe
with reconstructions chest thorax posterobasal segmental pulmonary emboli.
Also likely subsegmental L. lateral basal
branch.
2. Stable appearance of the chest with
right perihilar mass with lymphangitic
spread and extensive nodal metastases.
3. Moderate to large right pleural effusion
unchanged in size.
4. Pericardial effusion is resolved.

8/29 Portable chest one view 1. Iinterval worsening of volume loss with
Reason: lung cancer right peripheral density. Elevation of the
right hemidiaphragm. The cardiac
silhouette is mildly enlarged.
Consideration s/b given for either mucous
plug or potentially obstructing cancer.

8/30 Echocardiogram L. Vent systole function normal. R. side

chamber dilated especially right ventricle.
Small-moderate pericardial effusion on
right side without hemodynamic
consequences. Sinus tachycardia

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 DIAGNOSIS, PLANNING, IMPLEMENTATION & EVALUATION OF NURSING CARE
Nursing Diagnostic Statement Goals with Outcome Criteria Nursing Interventions Scientific Rationale for each Evaluation of Goals &
With Supporting Data (Short & Long-Term Goals) Intervention (include sources) Replanning

Impaired gas exchange related STG: Patient will verbalize Assess and monitor respiratory Increased respiratory rate, use
to altered blood flow to alveoli understanding of oxygen rate, depth, and effort, of accessory muscles, nasal
secondary to lodged embolus supplementation and other including use of accessory flaring, abdominal breathing,
as evidenced by dyspnea, therapeutic interventions by muscles, nasal flaring and and a look of panic in the
restlessness, tachycardia, depth end of day 9/4. abnormal breathing patterns client’s eyes may be seen with
of breathing, O2 4L nasal hypoxia
cannula. LTG: Patient will maintain Auscultate breath sounds every In severe exacerbations of
clear lung fields and remain 1 to 2 hrs. The presence of COPD lung sounds may be
free of signs of respiratory crackles and wheezes may alert diminished or distant with air
distress by discharge date. the nurse to airway obstruction, trapping.
which may lead to or
exacerbate existing hypoxia

Monitor the clients behavior Changes in behavior and

and mental status for the onset mental status can be early signs
of restlessness, agitation, of impaired gas exchange. In
confusion, and in the late the late states the client
stages extreme lethargy becomes lethargic and
somnolent
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 Monitor oxygen saturation An O2 sat. of less the 90%
continuously using pulse indicates significant
oximetry note blood gas results oxygenation problems.
as available.

Observe for cyanosis of the Central cyanosis of the tongue

skin especially note color of and oral mucosa is indicative
the tongue and oral mucous of serious hypoxia and is a
membranes medical emergency peripheral
cyanosis in the extremities may
If the client is acutely or may not be serious.
dyspneic, consider having the Leaning forward can help
client lean forward over a decrease dyspnea, possibly
bedside table if tolerated. because gastric pressure allows
better contraction of the
Schedule nursing care to diaphragm.
provide rest and minimize The hypoxic client has limited
fatigue. reserves. Increased activity can
increase hypoxia.

DIAGNOSIS, PLANNING, IMPLEMENTATION & EVALUATION OF NURSING CARE

Nursing Diagnostic Statement Goals with Outcome Criteria Nursing Interventions Scientific Rationale for each Evaluation of Goals &
With Supporting Data (Short & Long-Term Goals) Intervention (include sources) Replanning

PC:
Decreased cardiac output STG: Client will explain Assess client for chest pain
related to fluid in pericardial actions and precautions to take intensity location radiation
sac as evidenced by cardiac for cardiac disease by end of duration and precipitating and
tamponade, day 9/4 alleviating factors

LTG: Patient will demonstrate Monitor for symptoms of heart

adequate cardiac output as failure and decreased cardiac
evidenced by blood pressure output listen to heart sounds
and pulse rate and rhythm lung sounds note symptoms
within normal parameters for including dyspnea, orthopnea,
client; strong peripheral pulses paroxysmal nocturnal dyspnea,
and an ability to tolerate fatigue, weakness third and
activity without symptoms of fourth heart sounds crackles in
dyspnea, syncope, or chest lungs increased venous
pain. pressure greater then 16 cm
H2O and positive
hepatojugular reflex
/conversion/tmp/scratch/48723365.docx 12/8/2021
 Recognize the effect of sleep
disordered breathing in heart
failure

If chest pain is present have

client lie down, monitor
cardiac rhythm, give oxygen,
check vital signs,k run a
monitor strip, medicate for
pain and notify physician.

Monitor I&O’s If client is

acutely ill, measure hourly
urine output and note decreases
in output

Watch laboratory data closely

especially arterial blood gases,
electrolytes including
potassium, and B-type
natriuretic peptide BNP assay

Administer oxygen as needed

per physicians order

Serve small sodium restricted

low cholesterol meals

Monitor bowel function

provide stool softeners as
ordered caution client not to
strain when defecating

Assess client for understanding

of and compliance with
medical regiment including
medications activity level and
diet.

Teach symptoms of heart

failure and appropriate actions
to take if client becomes
symptomatic.

/conversion/tmp/scratch/48723365.docx 12/8/2021