Nursing Care Plan

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NR 340 – Clinical Assessment Guide with NCP Organizer
Student Name ____CP_____________________ Date _2/12/13_____ Pt Initials _MK_____ Medical Diagnosis

#1: Multiple coronary artery disease

Chief Complaint

#1 Use Quotes: ”Shortness of breath and chest pain for over a month now” on 2/6/13

on day of Admission
Chief Complaint

#1 Use Quotes: “Pain 8/10”

on day of your nursing care
Prior Illnesses

Hypertension, coronary artery disease, obesity, angina

Family History

Father passed away from a heart attack; Mother had a stroke

General Survey

Sex M

Race Caucasian

Age 74

Height 175cm

Weight 90.7 kg

Facial Expression/Contour/Symmetry symmetrical, tired Speech normal Mental Status oriented Level of Consciousness awake and alert to person, place, time Physical Distress 8/10 Emotional Distress tired, happy

General Survey

in two – three sentences: Mr. K was admitted 2/6/13 with complaint of SOB on exertion with angina. Multiple coronary artery disease discovered from L heart catherization. CABG x4 on 2/11/13 w/ use of L internal mammary artery to L anterior descending, reverse saphenous vein graft to the obtuse marginal, reserve saphenous vein graft to R posterior descending artery and R posterior arterial branch; epiciortic sonography; ligation of L atrial appendage. Today patient is stable, awake, oriented, and in high spirits; medicated for pain, mediastinal tubes removed 2/12/13.

Vital Signs

Time 9am

BP 110/95

P 98

R 18

Temp 100.1 F; oral

Cardiovascular System:
1. Skin:
-color: normal
-temperature: warm and dry to touch
-turgor: present
-diaphoresis: mild around forehead
-dryness: none
2. Pulses (radial, pedal, apical):
-rate: 98
-regularity: rhythm afib; epicardial pacemaker
-equality: bilateral radial and pedal pulse; palpable
-presence: all pulses present and palpable; S1 and S2 present; Doppler signal available to all -absence: none
3. Neck Veins:
-distention: present
-pulsation: present on L side; unable to palpate R due to intrajugular central line 4. Respirations:
-rate: 18
-character: expansion equal and bilateral; clear; not labored; pleural chest tube: serosanguinous -type: normal
5. Extremities:
-appearance TEDS; dressing along saphenous vein, limited ROM -color: normal
-temperature: warm and dry to touch
-edema: TEDS; no edema
-nail bed refill: 1 second refill; normal
Respiratory System:
1. Respirations:
-rate: 18
-pattern: not labored; normal
-chest symmetry: equal and bilateral chest rise
2. Breath Sounds:
-presence: present

-absence/diminished: n/a
-moisture: none
-dryness: none
3. Cough/Secretions:
-productive: no
-nonproductive: yes
-color of secretions: pleural chest tube; serosanguinous
-consistency of secretions:
-amount of secretions: 830 mL over a 24 hr period from mediastinal and pleural tubes 4. Cyanosis:
-lips: pink; normal
-circumoral: normal
-nail beds: normal refill; pink
-earlobes; warm; normal
Gastrointestinal System:
1. Nausea/vomiting:
-presence: none
-characteristics of emesis: n/a
2. Abdomen:
-distention, rigidity, ascites: soft, nontender, nondistended -scar tissue: none
-bowel sounds: present x4; normal
-visible masses: none
-presence of ostomies (describe fully): none
3. Stools:
-color: n/a
-character: n/a
-frequency: n/a
Genitourinary System:
1. Urine:
-color: amber; clear

-amount: 450 mL
-odor: n/a
2. Bladder:
-distention: none
3. Drainage/Discharge
-vaginal: none
-urethral: none
Neurological System:
1. Level of Consciousness:
-awake, alert & oriented to time, place, person: yes
-responds to verbal stimuli and/or painful stimuli: yes
-able to follow commands: yes; cooperative
-disoriented and stuporous: no; oriented
-comatose: no
2. Pupil Reaction:
-equality: bilateral response; eyes open
-constriction: normal
-dilation: size L2/R2
-reaction to light: PERLA
3. Movement:
-no weakness: none
-left or right weakness: none
-balance:...
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