HANOI MEDICAL UNIVERSITY
Advanced Nursing Program
Student’s name: Ly Thi Thao
Class: Y4Q – 41
NURSING CARE PLAN
I, ADMINISTRATIVE INFORMATION
1, Patient’s name: Dao Manh Hung
2, Age: 58
3, Gender: Male
4, Address: P501 D2 Trung Tu Dong Da Ha Noi
5, Date of admission: December, 16th, 2018
6, Unit - Room: Cardiovascular Centre, 144
7, Family support: Dao Phuong Linh, 0843514789
8, Date of care: December, 17th, 2018 (the first day of treatment)
II, PROFESSIONAL INFORMATION
1, Chief complaint on admission: Difficulty breathing, edema in lower extremities
2, Present history:
One week before admission, the patient started having difficulty breathing when
going up stairs. He did not have difficulty breathing at night, cough and chest pain. After
that, he had edema in legs that increased with walking, increased in evening and reduced
in morning. He increased 5 kilograms in 1 week. He was urinable. So he was admitted to
Hanoi Medical University Hospital and was treated in Cardiovascular Centre on
December, 16th, 2018.
3, Medical history
- Patient history: He has diagnosed mitral regurgitation since May, 2018 at Hanoi
Cardiac Hospital and took cordrone 200 mg 2 tablets/day
- Family history: No found any abnormal
4, Admitted assessment:
- The patient alert, communicable
- Difficulty breathing, NYHA II
- Edema in lower extremities (increase 5 kg compare with normal weight)
- No subcutaneous hemorrhage
- Vital signs: Pulse: 116 bpm Temperature: 36.5oC
RR: 20 bpm BP: 140/90 mmHg
- Cardiovascular system: Irregular heart beat
BP= 140/90 mmHg, Pulse= 116 bpm
Murmur in heart apex
Atrial fibrillation with 107 circle/min
- Respiratory system: Difficulty breathing when effort activity
Chest wall move with breathing, RR= 21bpm
Reduce ventilation
- Gastrointestinal system: Abdomen is soft, no distention
No hepatomegaly, no splenomegaly
- Neurology system: No found any abnormal
- Other: No found any abnormal
5, Medical diagnose: Heart failure, atrial fibrillation, mitral regurgitation, hypertension
6, Laboratory results:
Laboratory Rationale of abnormal results
Ref Range 16/12/2018
Tests
Biochemistry
2.76 – 8.07
Ure 10.3 Increase
mmol/L
Creatinine 53 – 110 µmol/L 130 Increase
202.3 – 416.5
Acid Uric 598 Increase
µmol/L
AST <40 U/L 81 Increase
ALT <41 U/L 70 Increase
CK
(Creatine < 190 U/L 282.0 Increase
kinase)
Na 135 – 145 mmol/L 139
K 3.5 – 5 mmol/L 4.4
Cl 93 – 113 mmol/L 100
Bilirubin
<17 µmol/L 15.5
total
Immune test
FT4 12-22 pmol/L 27.07 Increase
ProBNP < 125 pmol/mL 166.00 Increase
TSH 0.27 – 4.2 µUI/mL 6.86 Increase
Coagulation test
Prothrombin 70-140 % 56 Decrease
INR 0.8 – 1.2 1.45 Increase
Other test:
- ECG: 79 bpm, atrial fibrillation
Right ventricular hypertrophy
Abnormal QRS-T angle
Consistent with pulmonary disease
Abnormal ECG
- Doppler ultrasound: Mitral regurgitation
No dilation of left ventricular, reduce systolic function of left ventricular
(EF=40%)
Trial regurgitation
Moderate of increasing pulmonary artery pressure
Mild pericardial effusion
Pleural effusion in 2 lungs: Left pleural fluid is 54 mm
Right pleural fluid is 52 mm
- Thyroid ultrasound: Follicles in right lobe of thyroid gland
III, NURSING PROCESS (Date of care: 17/12/2018 the first day of treatment)
1, Nursing assessment
a, General condition
- Alert, communicable
- Edema in lower extremities (Reduce 3 kg compare with yesterday)
- Pink skin and membrane
- No fever, no subcutaneous hemorrhage
- Vital signs: HR=79 bpm Temperature: 36.5oC
RR: 20 bpm BP: 120/80 mmHg
b, Cardiovascular system
- Irregular heart beat
- Systolic murmur 3/6 in heart apex
- BP= 120/80 mmHg, HR=79 bpm
- Peripheral pulse is clear
- ECG: Atrial fibrillation, Right ventricular hypertrophy
c, Respiratory system:
- Spontaneous breathing
- RR: 20bpm
- No cough, no sputum
- No difficulty breathing
d, Gastrointestinal system:
- Abdomen is soft, no distention
- No hepatomegaly, no splenomegaly
- Bowel movement is normal
- No constipation, no diarrhea
e, Neurology system:
- No found any abnormal
f, Urinary system:
- Urine is yellow, clear
- Normal amount of urine
g, Other systems: No found any abnormal
2, Nursing care plan: 5 nursing diagnoses
- Mild edema related to heart failure
- Pulmonary congestion related to heart failure
- Reduce cardiac output related to heart failure
- Nutrition deficiency related to loss of appetite
- Risk for digoxin toxicity
NO 1:
ASSESSMENT:
- The client increase 2 kg compare with normal weight (increasing <5% body
weight)
NURSING DIAGNOSIS #1
Mild edema related to heart failure
DESIRED PATIENT OUTCOME (Measurable & Patient Centered)
- Relieve edema
NURSING INTERVENTIONS RATIONALE
1. Assess vital sign two times/day 1. Control vital sign to detect abnormal
such as pulse, blood pressure signs
2. Assess site, character and level 2. To choose appropriate interventions,
of edema example for severe edema the client
should rest totally in the bed, and in
case of mild edema, the client still
do gentle activities
3. Monitor intake and output 3. To assess and control edema, the
client should restrict fluid intake in
severe edema
4. Administrative medication for 4. Medication is the best way to reduce
the client as doctor’s order such edema. Loop diuretic helps inhibit
as loop diuretic sodium, chloride and increase
potassium reabsorption cause
elimination of water
5. Monitor side effect of diuretic 5. Diuretic medication can cause side
effects such as electrolyte disorder
EVALUATION OF DESIRED PATIENT OUTCOMES
- The client reduce edema
- He can do gentle activities
NO 2:
ASSESSMENT:
- No cough, no difficult breathing
- Ultrasound result: Pleural effusion in 2 lungs
NURSING DIAGNOSIS #2
Pulmonary congestion related to heart failure
DESIRED PATIENT OUTCOME (Measurable & Patient Centered)
- Relieve pulmonary congestion
- The client do not complaint about the pulmonary signs
NURSING INTERVENTIONS RATIONALE
1. Assess the client breathing pattern, 1. To control the client’s
monitor respiratory rhythm, auscultate respiratory function. The
breath sound, monitor SpO2. appearance of pleural fluid is
2. Ask the client about discomfort such urgent sign for him.
as difficult breathing, cough. 2. To detect as soon as possible
3. Provide the client appropriate position and give the client proper
with elevated head such as Fowler or interventions.
semi-Fowler. 3. To promote maximum chest
4. Instruct the client in deep breathing expansion.
5. Supply oxygen therapy if necessary 4. Help take more oxygen for the
and doctor’s order. body.
6. About diet, consultant the client 5. Avoid exertion breathing and
restrict fluid intake. help supply enough oxygen
for tissue.
7. Administrative medication as doctor’s 6. Avoid excessive fluid in lungs
order such as diuretic. that cause pulmonary edema,
life-threatening condition.
7. Diuretic help increase water
elimination.
EVALUATION OF DESIRED PATIENT OUTCOMES
- No sign of pulmonary edema
- Reduce fluid in lungs
NO 3:
ASSESSMENT:
- BP= 120/80 mmHg (reduce compare with admission 140/90 mmHg)
- Irregular heart beat
- Systolic murmur 3/6 in heart apex
- Refill < 2 seconds
- Pink skin, membranes
NURSING DIAGNOSIS #3
Reduce cardiac output related to heart failure
DESIRED PATIENT OUTCOME (Measurable & Patient Centered)
- Improve myocardial function
NURSING INTERVENTIONS RATIONALE
1. Assess vital sign three times/day such 1. To control myocardial
as blood pressure, pulse function and detect as soon as
possible when the status
2. Inspect skin, assess skin and become worse.
membrane for pallor. 2. This is sign of inadequate
3. Feel skin for warm or cold, wet or blood supply for tissue.
dry. 3. If the client’s skin is cold, this
is sign of inadequate blood
supply for tissue, If the skin is
wet, this is sign of pulmonary
4. Monitor urine output congestion.
4. Reduce cardiac output can
5. Administrative medication as doctor’s make decreasing urine output.
order. 5. Medication should give for
patient as 5 right: right
patient, right medication, right
time, right dose, right route.
6. Monitoring side effect can occur. 6. To detect as soon as possible
and give intervention early.
EVALUATION OF DESIRED PATIENT OUTCOMES
- The client condition is better
- No more signs of reducing cardiac output
NO 4:
ASSESSMENT:
- The client losses of appetite
NURSING DIAGNOSIS #4
Nutrition deficiency related to loss of appetite
DESIRED PATIENT OUTCOME (Measurable and Patient centered)
- Stimulant appetite
- Ensure supply enough nutrients for client
NURSING INTERVENTION RATIONALE
1. Divide into small meals in day 1. Help the client eat more and
instead of big meals. digest easily.
2. Change diet with different food, 2. Stimulant appetite for client.
different taste.
3. Encourage the client eat more 3. Help supply enough energy for
protein, enough carbohydrate, client. Vitamin group B can
more vitamins and minerals, stimulant appetite.
especially vitamin group B.
4. Limit salt, lipid, cholesterol. 4. That is harmful for cardiac
5. Control weight regularly. function.
5. Avoid malnutrition that cause lose
weight due to lose muscle and fat.
EVALUATION OF DESIRED PATIENT OUTCOMES
- No lose weight
- The client eat more than before
NO 5:
ASSESSMENT:
- The client uses digoxin
- And use loop diuretic: furosemide
NURSING DIAGNOSIS #5
Risk for digoxin toxicity
DESIRED PATIENT OUTCOME (Measurable and Patient centered)
- No signs and symptoms of digoxin toxicity
NURSING INTERVENTION RATIONALE
1. Monitor and detect the signs of 1. Knowing and detecting this
digoxin toxicity such as signs early is important to
bradycardia, headache, sweating, handle immediately.
nausea, vomiting…
2. Monitor the side effect of diuretic: 2. Electrolyte disturbance can
electrolyte disturbance. make increase risk for digoxin
3. Assess heat rate after giving IV toxicity.
digoxin and continuous several 3. Digoxin can make decrease
following days. heart rate dangerously.
EVALUATION OF DESIRED PATIENT OUTCOMES
- No signs of digoxin toxicity
IV, EDUCATION
1, Disease
- Heart failure is the chronic disease and is not cured totally.
- Help the client prepare, ready mentality to accept and live with disease.
- Explaining the purpose of using medication is to improve comfort feeling and
manage disease.
- Consultant for the client and family members about the invasive methods.
2, Medication
- Educate about the effect and side effect of medications that the client is using
- Notice to doctor or medical staffs if the side effect occurs
- Consultant the client and family members about the importance of following
treatment.
- Warning about anticoagulation effect: increasing risk for hemorrhage, so the client
avoid injuries that may occur.
3, Lifestyle:
- Exercise:
+ Avoid exertion exercise
+ Do suitable activities as the client tolerance that help training heart working
- Make life task at home such as planting tree, cooking…
- Food: Eat more protein, supplement vitamins and minerals; limit salt, lipid and
cholesterol.
4, Appointment with doctor
- Regular check with doctor as appointment
- Warning the dangerous signs needed to see doctor immediately such as dyspnea,
bruising, edema, decreasing urine output…
V, MEDICATIONS
Medication Dote and Indication ARDs
route
Furosemid 2 tubes - Edema due to the - Hypersensitivity
20 mg/2ml Intravenous origin of the heart, - Nausea, vomiting
injection in liver or kidney. - Chest pain,
the morning - Lung edema, cerebral dyspnea
edema, edema due to - Hypokalemia,
pregnancy poisoning. hypocalcemia
- Mild or moderate - Headache
hypertension. - Pallor, bruising,
hemorrhage
- Weight loss
Digoxin 0.5 1 tube - Heart failure (usually - Increased
mg/2ml IV injection in combination with ventricular
diuretics), especially stimulation.
when there is atrial - Rarely: allergies,
fibrillation. thrombocytopenic
- Supraventricular purpura, feminine
arrhythmias slow or breasts.
reduce atrial - Overdose:
fibrillation or atrial Gastrointestinal
flutter. disorders
- Precaution:
Toxicity
Valsartan 1 tablet - Hypertension - Viral infection
(Diovan) 80 Oral route in - Heart failure - Fatigue
mg the morning - Post myocardial - Abdominal pain,
infarction diarrhea, nausea
- Headache,
dizziness
- Upper respiratory
infection, cough
- Rhinitis, sinusitis
Kali clorid 2 tablets - Prevent and treat of - Nausea, vomiting
(Kaldyum) Oral route in hypokalemia - Diarrhea
600 mg the noon and - Abdominal pain
afternoon - Hemorrhage
- Ulcers,
perforation or
obstruction of the
gastrointestinal
tract.
Lovenox 40 1 syringe - Prevent and treat - Mild irritation,
mg/0.4 ml Subcutaneous harmful blood clots pain, bruising,
injection in redness, and
the morning swelling at the
injection site.
- Fatigue or fever
