Langston University
Baccalaureate Nursing Program
Care Plan Level I
Student Name:
Perla Salas
Clinical Site: Adult Health
Date: 8/30/2021
Client Initials: . Age: 68 Sex: F Admission Date: 07/16/2009
Cultural Consideration(s):
History of Alzheimer’s Disease, Heart failure, Type 2 Diabetes, Anxiety
NURSING MANAGEMENT
Priority Nursing Diagnosis
Heart Failure
MEDICAL MANAGMENT
Admitting Medical Diagnosis:
Alzheimer’s Disease
Medical Management: N/A
Subjective data: Heart palpitations,
Fatigue, Anxiety
Objective data: Restless,
tach/bradycardia
NURING MANAGEMENT
Nursing Diagnosis #2
GERD
Subjective Data: Insufficient interest
in food, inability to ingest food
Objective Data: Weight loss with
adequate food intake. Food intake less
than recommended daily allowances.
.
Lab: N/A
Treatments:
Medications:toEliquis,
Pantoprazole
Client Outcome
Verbalize knowledge of
the disease process,
individual risk factors,
and treatment plan.
Client Outcome
Verbalize understanding of
causative factors when known
and necessary interventions.
Interventions & Rationales
Interventions & Rationales
1. Monitor vital signs frequently (to note response to activities and
interventions)
2. Monitor the rate of IV drugs closely, using infusion pumps, as appropriate (to
prevent bolus or overdose).
3. Encourage relaxation techniques (to reduce anxiety, muscle tension).
1. Determine lifestyle factors that may affect weight (Socioeconomic
resources, amount of money available for purchasing food,
proximity of grocery store, and available storage space for food are
all factors that may impact food choices and intake).
2.Consult with dietitian or nutritional support team, as necessary, (for
long-term needs).
3. Ascertain understanding of individual nutritional needs (to determine
informational needs of client/SO).
4.
Evaluation
1. Client’s response to interventions, teaching, and actions
performed.
2. Attainment or progress toward desired outcome(s).
3. Modifications to plan of care.
Evaluation
1. Results of periodic weigh-in.
2. Client’s responses to interventions, teaching, and actions
performed.
3. Modifications to plan of care.