HOWARD COMMUNITY COLLEGE

NURSE EDUCATION PROGRAM

NURS-240 NURSING CARE PLAN
Student Name: Kayla Hunley
Students Clinical Instructor: Kathleen DeSantis_________
Clinical Agency: Howard County General Hospital______
Date Submitted: _October 6, 2014________
Patient Initials: LT

Age: 93

Sex: Female

Date of Patients Admission: 9/8/14

Admitting Medical Diagnoses (1) Atrial Fibrilation
(2) Hypothyroid___________
(3) CVA_________________
(4) Urosepsis ____________

Patients Past Medical History: Diabetes mellitus, A-Fib, Senile dementia, Thyroid Disease

Diversity/Cultural Considerations for the patient: None stated

NURS-240

Complete the following table in detail:

Medications
(generic and
trade names;
include
prescription
and onprescription
medications)
Heparin

Drug
Classification

Dose

Frequency

The reason this

patient is
taking this
specific
medication

Parameters to
be checked
prior to
administration

Patient safety:
when to hold
the medication &
follow up required

Side effects
of the
medication
and required
follow up

Patient
Teaching

Anticoagulant

5,000
Units

Q 8 Hours

Prevention of
thrombus
formation

INR, PTT, PT

Hold if
uncontrolled
bleeding or open
wounds, severe
thrombocytopenia
, hypersensitivity

Drug
induced
hepatitis,
alopecia,
bleeding,
HIT, anemia

Aspirin EC
tablet

Salicylates

81 mg

Daily

Prophylaxis of
TIA and MI

Last dose

Hypersensitivity,
bleeding disorders
or thrombocytopenia

Tinnitus, GI
bleeding,
dyspepsia,
nausea,
abdominal
pain,
anorexia,
increased
bleeding
time

Insulin Regular
(HumuLIN R,
NovoLIN R)

Antidiabetics,
hormones
pancreatics

1 unit

TID AC

Control of
hyperglycemia

Last Dose
Glucose Level

hypoglycemia,
allergy or
hypersensitivity

Hypoglycem
ia, erythema,
pruritis,
swelling

Report any
symptoms of
unusual
bleeding or
bruising to
HCP
immediately.
Carry an ID
card with this
information
at all times.
Take with a
full glass of
water and to
remain in an
upright
position for
15-30 mins
after
administratio
n.
Report
tinnitus,
unusual
bleeding of
gums;
bruising;
black tarry
stools; or
fever lasting
longer than 3
days
Teach proper
technique for
administratio
n
Teach patient
that insulin
treats
hyperglycemi
a but does
not cure
diabetes.
Therapy will
be long term
S/S of
hypoglycemi
a and what to
do if they

NURS-240

Acetaminophe
n (Tylenol)

Antipyretic,
nonopioid
analgesics

650m
g

Q 4Hour
PRN

PRN for pain

Last dose
Pain level

Hypersensitivity,
hepatic
impairment/
active liver
disease

Hepatotoxici
ty (in High
Doses),
Increased
liver
enzymes,
renal failure,
neutropenia

occur
Take exactly
as directed
Avoid
Alcohol
Can alter
blood
glucose
monitoring
results

Complete the following for your patients primary admitting diagnosis.

Cite the references used.
I.

Medical Diagnosis: Atrial Fibrillation

II.

Pathophysiology:
Atrial Fibrillation (AF) is the most common type of arrhythmia. The dysrhythmia may
begin and end spontaneously or may be persistent. It is characterized by total disorganization of
atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction.
Causing the atria to contract very fast or irregularly. In AF, blood pools in the atria and doesnt
completely pump into the ventricles causing the chambers to not work together as they should. AF
results in a decreased cardiac output because of ineffective contractions and/or rapid ventricular
response. Clots form because of the stasis of blood (a clot can form/pass to the brain and cause a
stroke or dislodge to another place in the body). Structural Heart Disease is the underlying cause
in many cases of AF however; the cause in healthy normal hearts is less well understood.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page827

III.

Etiology of the condition (underline the etiologies that relate to your patient):
Known risk factors for AF include age, male sex, valvular heart disease, hypertension, and
diabetes. Most often AF is associated with an underlying structural heart disease such as valvular
problems, heart failure, coronary artery diseases, congentital heart disease, cardiomyopathy, and
septal defects. AF can be secondary to reversible causes and treatment of the underlying disease
usually gets rid of the arrhythmia. Some of the most common causes are alcohol intake, infectious
state, heart attack, hyperthyroidism, and pulmonary embolism.
Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
NURS-240

Page 827

IV.

Clinical Manifestations (underline the signs/symptoms your patient is experiencing):

Signs and symptoms can include palpitations, shortness of breath, weakness, chest
pain, dizziness or fainting, fatigue, confusion and a rapid heart rate. Some patients may be
asymptomatic or relate their symptoms to something else such as a cold or just getting
old. During atrial fibrillation, the atrial rate may be as high as 350 to 600 beats/min. P
waves are replaced by chaotic, fibrillatory waves. The PR interval is not measurable, and
the QRS complex usually has a normal shape and duration.

Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page827

V.

Medical Treatment:
The goals of treatment include a lowered heart rate, prevention of cerebral events,
and conversion to sinus rhythm, if possible. Drugs used for rate control include
calcium channel blockers, Beta-adrenergic blockers, Digoxin, and dronedarone. For
some patients, pharmacological or electrical conversion back to sinus rhythm may
be a consideration. For a patient in AF longer than 48 hours, anticoagulation therapy
with Warfarin is needed for 3 weeks before cardioversion and for 4 weeks after a
successful cardioversion. Anticoagulation therapy is needed because the
cardioversion can cause clots to dislodge and can place the patient at risk for stroke.
If it is found that no clots are present, anticoagulation therapy is not needed before
the cardioversion.

Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.
Page 827

VI.

Nursing Management:

NURS-240

VII.

Lab Analysis/diagnostic tests:

Lab test or
Diagnositic
test

Date
of
the
test

Results of
the lab or
diagnostic
test

Normal
Values of
the lab or
diagnostic
test

WBC
RBC

9/18
9/18

6.52
3.42

4.0-11.0
F 3.8-5.1

Hemoglobi
n

9/18

10.3

F 11.715.5

Hematocrit

9/18

30.2

F 35%47%

Sodium
Potassium
Chloride
CO2
Glucose

9/19
9/19
9/19
9/19
9/19

140
4.0
100.4
32
177

135-145
3.5-5.0
95-105
32-48
70-99

NURS-240

Analysis of
the results:
normal,
abnormal,
elevated or
decreased;
Explain the
reason for
any
deviations
from the
norm
Normal
LOW can
be from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
LOW -can be
from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
LOW- can be
from
hemorrhage,
dietary
insufficiency,
chronic
illness,
hydration
status
Normal
Normal
Normal
Normal
HIGH diet

Current
medications
which may
affect the
results, of
any
(explain
how)

Nursing
Actions
related to
the results

None

Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency

None

Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency

None

Increase
fluids to
hydrate,
evaluate
vitamin or
mineral
deficiency

Salicylates

Level taken

controlled
DM (before
insulin
therapy)
Creatinine
Calcium

9/19
9/19

0.5
8.2

0.6-1.3
8.6-10.2

Normal
LOW

Albumin

9/18

2.1

3-5

LOW

Magnesium

9/18

1.6

1.5-2.5

Normal

(acute
toxicity) Aspirin

before or
after meal?
Monitor
diet,
administer
Insulin

Aspirin,
Heparin,

Occurs with
low albumin
levels,
assess
nutrition and
assess for
vitamin D
deficiency
Hepatotoxic Assess for
drugs
malnutrition
, over
hydration,
third space
losses

Pagana,K.D.,&Pagana,T.J.(2010).ManualofDiagnosticand
LaboratoryTests(4thed.).St.
Louis,MO:Mosby.

VIII.

Discharge Planning

Assess your patients learning needs and ability

o Patient can listen and obey simple commands, however, she is not oriented to
place/time, just to self. Patient is total assist. All interventions and necessary
information should be discussed to patient, however, family members and
nursing staff should be instructed on the patients health care regimen since the
patient will not be able to perform health care needs her self.

Identify barriers to learning

o Altered mental status
o Total assist
o Poor communicator

Describe the patients home environment

o Nursing Home

NURS-240

IX.

Describe environmental or family/social support concerns

o Children provide information as needed
o Patient admitted for a fall in nursing home again supervision

Client Teaching

Knowledge and skills needed to manage illness/condition at home

o Nursing staff at long term care facility need to be educated on the patients
condition and medication regimen
o Children need to be educated on health care regimen for their mother should
they want to help with palliative care.

Medications
MED Chart

Diet
Enteral Feeding 40mL/hr with a 100mL flush every 6 hours

Activity
o Total Assist
o Passive ROM
o Turn in bed q 2hr

X.

Treatments
Patient is DNR, no heroic measures to be performed. Palliative care only.
Anticoagulants for prevent blood clots, Aspirin to prevent MI, Insulin to control DM,
acetaminophen PRN for pain
Safety
Call light in reach, side rails up, HOB up, bed low, brake on, Aspiration Precautions
Growth & Development
Patients age: 93
According to Erikson: Stage: Integrity

Crisis: Despair

Normal Developmental Tasks for this Stage:

A. Describe your patients ability to achieve their growth and developmental tasks.
a. The patient is total assist and bedridden. The patient is unable to communicate
well. She can follow simple commands and answer yes or no questions
however; she does not speak otherwise and only moans. The patient needs total
assistance with ADLs such as bathing, oral care, changing, etc. The patient has
a Foley catheter and does not get up to use the bathroom and she had a G tube
running continuously at 40 mL/hr. The patient is frail and has a very weak left
NURS-240

side due to a CVA. She also has an altered mental status, she is oriented to
herself but not to time/place.

B. How is this ability affected by the underlying disease process and/or the current
admission?
Patient was admitted to ED due to a fall at the nursing home where she lives. Nurses
at the long term care facility reported a change in LOC one day after the fall and patient
was sent to ED. Daughter reports that the patient normally communicates and talks
well, however, the patient is unable to communicate well and can only use simple
words such as yes or no. Patient can follow simple commands but is only oriented to
self, not place or time. The patients ability to perform ADLs is impaired due to old age
(muscle weakness), recent stroke (left side impaired), and altered mental status.
Daughter reported to her knowledge that the patient was not on any anticoagulation
medication for her A-Fib. This underlying condition could have possibly caused blood
clots that could have caused her recent stroke.

C. List nursing actions to assist your client in meeting their growth and developmental
needs.
Keep patient and family members/nursing staff at long term care facility educated
on the medication the patient is prescribe to make sure she takes it properly when being
discharged and to ensure understanding of why the medication is being taken.
Keep patient informed on a heart healthy diet (if PO again) and ensure that she and
family members understand why it is important to keep up on a healthy diet.
Assist the patient in ROM exercises to help with the contractures associated with
recent stroke to help recovery, prolong life, and increase independence if possible.
It seems the patient has a relatively good relationship with her children and family
based on the information provided from her children and the way in which he daughter
speaks fondly of her mother. The patient will be able to reach Integrity over Despair as
long as her relationship with her children remains strong; the patient is likely to feel
satisfied with what she will leave behind for her family. It is hard to make an inference
on this matter since the patient was not able to communicate well in order to provide a
good insight on her life overall.

NURS-240

XI.

List in priority order all relevant nursing diagnoses for your patient. Include NANDA
diagnosis, etiology, and supporting data. Identify in order the top three priority diagnoses.

Risk for decreased Cardiac Output

Risk for decreased cerebral tissue perfusion related to decreased cardiac output
Risk for ineffective peripheral tissue perfusion related to decreased cardiac output
Decreased cardiac output related to rapid heart contraction as evidenced by heart rate >100 BPM on admission
Impaired gas exchange related to shortness of breath as evidence by labored breathing
Risk for activity intolerance related to shortness of breath

Assessment Data:

Nursing Diagnosis

Nursing Actions

Rationale

Evaluation

Identify all data that support

the selected nursing
diagnosis.

(According to NANDA)

List in order of priority.

Label aspect of care.

State the rationale for each

nursing action. Cite
reference and page number.

Evaluate each nursin

Revise nursing actio
necessary.

Diagnosed with atrial

fibrillation with rapid
ventricular response

Risk for ineffective

cerebral tissue
perfusion related to
decreased cardiac
output.

Patient Heart rate on

admission was 121
BPM and fluctuating
from 80 BPM to about
120 BPM throughout
the clinical day
Patient was admitted
with blood pressure of
131/90 and then
dropped to 90/60
Patient has decreased
breath sounds
Patient RBC count is
low at 3.42
Low albumin at 2.1 and
low calcium at 8.2

NURS-240

1. Monitor
patients
blood
pressure
closely and
monitor for
need of
medication to
regulate
high/low
pressure if
needed.
2. Monitor
patients vital
signs and
keep patient
on constant
heart
monitor.
3. Correct
electrolyte
imbalance
4. Draw
patients INR
and PT time
per MD
order,
administer
Heparin per
order/ if
needed.

1. Patients blood
pressure keeps
fluctuating
from
hypotensive to
hypertensive. It
would not be
therapeutic to
give the patient
a calcium
channel blocker
etc. If the
patients blood
pressure is
stable.
However,
should the
patient need an
anti
hypertensive,
constant
monitoring of
blood pressure
can ensure a
quicker
response,
should there be
a change in
condition.
2. It is important
to monitor vital

1. Patients
pressure
remained
normal li
througho
clinical d
(110/58 a
2. Patients
signs wer
normal li
during cl
day, exce
HR woul
fluctuate
80s-120
3. Patient r
continuo
enteral fe
(Glucern
40ml/hr w
100ml NS
every 6 h
4. Patients
PT time l
not avail
the MAR
review, r
were still
pending.

5. Patient w

5. Assess need
for a Social
work consult
for education
on programs
available for
medication
cost
6. If needed, an
echocardiogr
am can be
performed in
order to rule
out the
presence of
clots in the
atria.

NURS-240

signs and have

necessary
equipment
available in
order to notice
a change from
baseline to
gauge a patients
recovery or if
their condition
is getting worse.
Many times
signs and
symptoms are
not present so
changes in
vitals are
indicating
factors.
3. Electrolyte
imbalances can
cause confusion
and change of
LOC, as well as
cause muscle
irritability and
contractions
especially in the
heart.
4. Risk of stroke
in AF greatly
increases at
INR levels less
than 2.0.
Efficacy and
safety of
anticoagulation
for AF depend
on maintaining
the INR
between 2.0-3.0.
Heparin is an
anticoagulant,
used as
prophylaxis of
thrombus
formation to
prevent a CVA.
5. Often social
workers can

unable to
commun
well, thes
should be
discussed
patients
daughter
possibly
staff from
term car
6. Patient is
and no h
measures
be perfor
this patie
Cardiove
will not b
performe

provide patients
with
information for
appropriate
resources to
help people who
cannot afford
their
medications.
This is to ensure
compliance to
the medication
regimen and
prevent
noncompliance
due to financial
issues before
they even occur.
6. If there are no
clots present in
the atria,
anticoagulation
therapy is not
required before
cardioversion
therapy (if
needed). Also, if
clots are found
this allows the
medical staff to
prepare/caution
for increased
risk of stroke
Expected Outcome:

NURS-240

STG: Patient will

revert back to sinus
rhythm with 24
hours.

LTG:
Patient or family
member will
verbalize 2 ways to
help ensure
medication
compliance and 5
ways to help prevent
falls at home before
discharge.

Evaluate each
expected outcome:

STG: Goal not met,

patient in AF for
more than 48 hours.

LTG: Goal not met,

discharge was not
discussed and no
family member
present to help
communicate those
measures.

NURS-240

Assessment Data:

Nursing Diagnosis

Nursing Actions

Rationale

Evalua

Identify all data that support the

selected nursing diagnosis.

(According to NANDA)

List in order of priority.

Label aspect of care.

State the rationale for each nursing

action. Cite reference and page number.

Evaluate
nursing a

Risk for decreased

Cardiac Output d/t
rapid, ineffective
contractions of the
heart.

1. Palpate radial,
carotid, femoral,
and dorsalis pedis
pulses, noting rate,
amplitude and
symmetry.
Document.

1. Difference in equality, rate,

and regularity of pulses are
indicative of the effect of
altered cardiac output on
systemic and peripheral
circulation.

-Altered heart rate/

rhythm, PT diagnosed
with A-Fib
-RBC count/ Hgb,
Hematocrit all low.
- RBC 3.42
- Hgb- 10.3
- Hematocrit 30.2%
-Calcium level low at 8.2
-Albumin low at 2.1

NURS-240

1. All p
present
on left
extrem
noted w
than th
extrem
This m
2. Auscultate heart 2. Specific dysrhythmias are
due to l
sounds, noting
more clearly detected audibly
movem
rate, rhythm,
than by palpation. Hearing
the left
presence of extra
extra heartbeats or dropped
Passive
heartbeats, and
beats helps identify
exercise
dropped beats.
dysrhythmias in an
perform
unmonitored client.
help inc
3. Administer
blood f
supplemental
3. This increases the amount of the extr
oxygen, as
oxygen available for myocardial Nurse o
indicated
uptake, reducing irritability
made a
caused by hypoxia.
4. Monitor
2. Patie
laboratory studies, 4. Electrolyte imbalances, such
chronic
especially
as potassium, magnesium, and
Dysryh
electrolytes. And
calcium adversely affect cardiac already
use therapeutic
rhythm and contractility. Also,
identifi
measures to
Hypoalbuminemia is often
before
correct
associated with anemia.
to hear
imbalances.
(Potassium imbalance is the
howeve
number one cause of AF)
listenin
5. Provide calm
heart so
and quiet
5. This reduced stimulation and always
environment
release of stress-related
import
catecholamine, which can cause listen fo
or aggravate dysrhythmias and murmu
vasoconstriction, increasing
irregula
myocardial workload.
3. Patie
oxygen
nasal ca
Oxygen
checked
occasio
make s
was bei
admini
properl
HOB k

least 30
to ease
breathi
for asp
precaut
4. Patie
receivin
enteral
of Gluc
40mL/h
100mL
every 6
continu
monito
values a
adjust f
approp

5. Patie
TV on i
on a low
volume
low, wi
patient
cracked
door w
mostly
keep ou
hallway
howeve
closed a
way so
patient
closely
monito
she cou
commu
well. P
was app
in a cal
manner
she wou
be start
Expected Outcome:

NURS-240

STG:
Heart rate and
rhythm converted
back to sinus
rhythm to sustain
adequate cardiac
output and tissue
perfusion within 48
hours.
LTG:
Achievement of
activity level
sufficient for basic
self-care before
discharge.

Evaluate each
expected outcome:

STG: Goal not met,

patient in AF for
more than 48 hours.

LTG:
Goal not met,
Patient has not been
considered for
discharge at this
point. Patient is total
assist and on enteral
feedings.

Doenges,M.E.,Moorhouse,M.F.,&Murr,A.C.(2014).Guidelines
forIndividualingClientCare
AcrosstheLifeSpan:NursingCarePlans(9thed.).
Philadelphia:DavisCompany.
Pages9293

Lewis,Dirksen,Heitkemper,Bucher,&Camera.(2011).Medical
SurgicalNursing(8thed.).St.Louis,
MO:Elsevier.

NURS-240

NURS-240