NURSING CARE PLAN SAMPLE DATABASE Mr. Jose Rodriguez, an 84-year-old client, was admitted to the hospital on 6/20/02 with shortness of breath. This retired Hispanic grower, a widower, states that for the past 3- weeks he has had increasing -4 fatigue and shortness of breath. He visited his doctor two days ago, and his medication was increased. His preferred foods are fresh fruits and vegetables, rice, red beans and tortillas. Mr. Rodriguez lives with one of his daughters and her family since experiencing a myocardial infarction in 1988. He has six other children. He is a Catholic and attends church regularly; however, since his declining health, he has been confined to his home. He is visited at home weekly by his church pastor and/or representative. He speaks with pride about his grocery store that he started for his family. He smoked two packs per day x 40 years and quit in 1990. Mr. Rodriguez was admitted with a diagnosis of chronic congestive heart failure (CHF) with acute exacerbation. His medical history includes coronary artery disease x 10 years. He had a balloon angioplasty in 2000 and an M.I. in 1988. He is hearing impaired and wears bilateral hearing aids. He wears glasses and reads without difficulty. This is his third admission for CHF since his diagnosis five years ago. Physician progress notes from 6/22/02 state: Condition improving; c/o decreasing SOB; chest x-ray improving; serum K+ is 3.3, and weight decreased 8# in past two months. Admitting history and Physical exam 6- -02 -20Moderate respiratory distress; crackles auscultated in left lung base Currently sleeping on 3 pillows at night to ease breathing. Nocturia X4 this past week. Mild heart murmur; no JVD, peripheral pulses +2; VS: 98.6- -28, 176/94, Ht. 5’7”, Wt. 154#, Baseline BP 145/90 -88c/o increasing fatigue and severe shortness of breath (SOB) O2 SAT level - 90% on room air. Denies chest pain. 6- -02 -206- -02 -206- -02 -206- -02 -206- -02 -206/22/02 6/20/02 Digoxin 0.25 mg po QD Lasix 40 mg po bid Nitro-Bid 2.5 mg po qid Metamucil 15 ml po q hs in glass of water/juice KCl 20 mEq po bid Chest x-ray-mild left ventricular hypertrophy; pulmonary congestion resolving. Serum electrolytes: Na+ 138 mEq/L K+ 3.3 mEq/L Ca+ 9.1 mg/dl CL- 102 mEq/L Serum albumin 2.8 g/dl Serum digoxin level 2.6 ng/dl Bun 30 mg/dl Cr 0.6 mg/dl
Diagnostic tests results
6/20/02 6/20/02 6/20/02 Other admitting orders
No added salt diet; I & O, daily wts, activity as tolerated BRP with assist, VS Q 4 hours O2 at 3L/min per nasal cannula Heparin lock States “my old heart is just wearing out. I get this extra fluid every now and then. I come here to the hospital to get rid of it.” Seems well oriented and is a fluent historian; accurately reported meds he had been on at home. c/o constipation. Skin reddened over bony prominences. Currently requires HOB elevated to ease breathing. Requires W/C for transport. Needs ADL assist. Gait unsteady. Family at bedside. - -1NSGCAREPLAN(Sample):1:1/06
Nursing Interview & Observations
SAMPLE NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATION STUDENT________________________________ SEMESTER INSTRUCTOR____________________________ ROTATION Client’s Initials J.R. Gender M Age 84 Code Status Full Admission Date 6- -02 -20-
Presenting Signs/Symptoms (What brought the client to the hospital?) Increasing fatigue and SOB x 3- weeks -4 Admitting/Primary Diagnosis Chronic CHF with acute exacerbation Surgeries Related to this Admission None
Secondary Diagnoses (Diagnoses other than admitting diagnosis that impact this admission.) CAD (coronary artery disease). S/P MI (1988) History of Present Illness (What led up to this hospitalization?) Client became more SOB and tired 3- weeks ago. Lasix was increased to 40 mgs qd on 6/18/02. Presented to -4 E.R. with ↑ SOB and dyspnea. Previous Surgical Procedure(s) / Date(s) Balloon Angioplasty (1 vessel) 2000 Health History (Include length of time client...