Cardiovascular: Decreased cardiac
output r/t congestive heart failure and
myocardial infarction
Pt. has a history of CHF and an AV
sequential pacer that, when investigated,
was found to only be pacing the right
ventricle. When pt. presented to ED his BP
was 130/80 and he had <30 mL or urine
output/hour for the first few hours that he
was at EAMC. The pt. was also confused,
disoriented, and his extremities were
edematous.
Interventions: Assess for signs and
symptoms of decreased CO. Implement
measures to improve CO such as: place pt.
in Semi-Fowler’s position; administer
diuretics, beta-blockers, and positive
inotropes per MD order
Goals: Pt. will have improved cardiac output
AEB: BP within normal range for pt., usual
mental status, urine output of at least
30mL/hour, and a decrease in edema. Goals
partially met
Neurological: Altered mental status
Pt. is confused upon awakening but slowly becomes more oriented. Pt. is
oriented to person and place but cannot recall numbers such as his phone
number or address. Pt.’s daughter states that this is unusual for pt.
Interventions: Assess for and monitor acute changes in cognition, treat
underlying cause of altered mental status (decreased cardiac output and
impaired gas exchange), use orientation techniques such as placing a clock
and calendar in pt.’s room, explain hospital routines and procedures
slowly and in simple terms
Goals: Pt. will be orientated to person, place, and time. Pt. will
demonstrate return of mental status to baseline. Goals not yet met
Medical Diagnosis:
Myocardial Infarction,
Altered Mental Status
Primary Nursing
Diagnosis: Decreased
cardiac output
Respiratory: Impaired gas exchange r/t decreased pulmonary
tissue perfusion associated with decreased cardiac output
Pt.’s RR was 40 when he was admitted to the ED but they are now in
the high 20’s to low 30’s. The pt. was extremely SOB upon arrival. He
also has diminished breath sounds with coarse crackles over the
lower lung fields. Pt.’s pulse oximetry is around 96% on 4L O2 via NC.
His O2 sat’s drop significantly when the NC is removed. The pt. still
has some confusion and disorientation.
Interventions: Assess for signs and symptoms of impaired gas
exchange and implement measures to improve gas exchange such as:
perform actions to improve cardiac output, place client in a SemiFowler’s position, instruct client to use incentive spirometer Q2H,
and maintain O2 therapy as ordered.
Goals: Pt. will experience improved gas exchange AEB: normal rate,
rhythm, and depth of respirations; pt. states a decrease in dyspnea;
improved breath sounds; usual mental status; and pulse oximetry
results within normal range. Goals partially met
Past Medical History:
Pt. has a history of CHF,
type II diabetes, has an
AV sequential
pacemaker (after
investigation it was
found that the
pacemaker was only
pacing the right
ventricle), and a pelvic
CT revealed a renal
mass that is suspicious
of renal carcinoma
Genitourinary: Risk for infection r/t
urinary catheter
Pt. has had a Foley catheter in place for
2 days. Pt’s temp is 96.7° F, WBC count
is 10.1.
Interventions: Follow EAMC protocol
for catheter and perineal care, monitor
urinary output Q2H, monitor pt.’s
temp. and WBC count
Goals: Pt. will remain free of infection
AEB: normal temp. and WBC count
within normal limits. Goals partially
met
Present Illness: Pt. was
discharged from EAMC on
9/28 after an exacerbation
of his CHF. Late on 9/28,
the pt. became short of
breath and was brought to
Clay County hospital which
then transferred him to
EAMC. At the time of
admission, pt.’s RR was 40,
BP was 130/80, K was 6.3,
BNP > 5000, and troponin
was 1.9
Gastrointestinal: Risk for constipation
Pt. has not had a BM since admission to the ICU. Pt. does
have a soft, rounded abdomen and has been passing gas.
Pt. also has limited mobility r/t his heart catheterization
earlier today.
Interventions: Provide pt. with a high fiber diet,
administer stool softeners per MD order, continue to
palpate pt.’s abdomen for distention and auscultate for
bowel sounds.
Goals: Pt. will not experience constipation AEB: pt.
maintains passage of soft, formed stool Q1-2 days
without straining; absence of abdominal distention and
pain. Goals not yet met
Integumentary: Risk for
infection
Pt. had a heart
catheterization performed
earlier today. Pt’s temp is
96.7° F, WBC count is 10.1.
Interventions: Assess for and
report signs of site infection
such as: fever, redness,
swelling, and pain at the site;
unusual site drainage; and an
elevated WBC count. Perform
actions to reduce
introduction of pathogens to
the site by: maintaining good
hand hygiene and instructing
pt. to refrain from touching
site
Goals: Pt. remains free from
infection at the
catheterization site AEB:
absence of fever, heat,
redness, and pain at the site;
usual drainage from site; and
WBC count within normal
range. Goals partially met