Patient Name: D.C.
Age: 65
Room# 4026-2
Code: Full
Medical Diagnoses
Definition/Explanation
Related Nursing
Diagnoses/Intervention
Related Tests/Results
*Dyspnea
* reason for admission
*COPD
*reason for admission
Shortness of breath or difficulty in breathing: May be
caused by heart conditions, strenuous exercise or severe
anxiety
RISK FACTORS: congestive heart failure, COPD, asthma,
hypertension, pneumonia or pulmonary infection,
smoking or chronic lung disease
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Chronic Obstructive Pulmonary Disease: a progressive
and irreversible condition characterized by diminished
inspiratory and expiratory capacity of the lungs.
Exacerbated with physical exertion, of difficulty in
inhalation or exhalation and sometimes a chronic cough
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RISK FACTORS: Occupational hazards and exposure to
dust and chemicals, age, genetics, people with asthma
who smoke, second hand smoke exposure
*Congestive Heart Failure A condition in which the heart cannot pump enough
blood in relation to the venous return and the metabolic
(CHF)
*reason for admission
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requirements of body tissues.
RISK FACTORS: coronary artery disease, hypertension,
valvular heart disease, infections, bacteria, parasites,
drug and alcohol abuse, tachycardia, obstructive
cardiomyopathy
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Risk for activity intolerance
o Provide O2 as
needed
o Reduce activity
levels
o Monitor for edema
o Administer
medications to help
with retention of
fluids
Ineffective airway clearance
o Provide O2 therapy
to the client as
needed
Activity Intolerance
o Assess the individual
response to the
activity; pulse, blood
pressure,
respiration.
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Chest radiograph
Electrocardiograph
Screening spirometry
see notes under CHF for
results of tests

Decreased cardiac output
related to impaired
contractility and increased
preload and afterload
o Provide bedside
commode to reduce
work of getting to
bathroom for
elimination
Impaired gas exchange related
to alveolar edema due to
elevated ventricular pressures
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Spirometer (lung function
test)
Forced vital capacity (FVC)
lung test
Residual volume (RV) lung
test
Total lung capacity (TLC)
lung test
Diffusing capacity lung test
patient was not tested for
any of these during her stay
at NRGH.. this likely would
have been done prior to her
diagnosis of COPD years
prior
Serum lipid levels
ECG
Chest X-ray
echocardiogram
ejection fraction 35%
pan chamber enlargement
aortic valve minimally
sclerotic with signs of aortic
stenosis
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o
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Hypertension
Hypertension- a common, often asymptomatic disorder
which is characterized by elevated BP persistently
exceeding 140/90mm Hg. Essential HTN is the most
common kind of HTN and has no identifiable cause

RISK FACTORS: age; race; family history; weight; physical
activity deficit; smoking; excessive sodium intake; stress;
Potassium or Vitamin D deficiency; excessive alcohol
intake; high cholesterol, sleep apnea; kidney disease

Raise head of bed to
reduce venous
return to heart and
lungs: alleviates
pulmonary
congestion
o Administer O2 ad
directed
Excess fluid volume related to
sodium and water retention
o Administer diuretics
as ordered
o Keep track of input
and output
o Weigh patient daily
to monitor edema
Decreased cardiac output
o Monitor blood
pressure
o Monitor peripheral
and central pulse
quality
o Observe skin color,
moisture, temp and
cap refill
o Observe for general
edema
Risk for ineffective tissue
perfusion (cardiac, cerebral,
periphery and visceral)
o Maintain bed
rest/elevate head of
bed
o Assess BP both lying
and standing
o Measure input and
output
o Monitor
electrolytes, BUN
and creatinine levels
o Ambulate to ability;
avoid exertion and
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Blood Pressure
measurements
patient’s postural BP
averaged around 88/57
supine and 92/56 standing
fatigue
Microcytic Anemia
Any time of anaemia characterized by small red blood
cells. Blood cells are also hypochromic (paler) and
therefore the concentration of hemoglobin is lower

RISK FACTORS: iron deficiency, premenopausal women,
older adults, alcoholism, chronic or critical injuries, iron
poor diets, excessive exercise

Diabetes Mellitus 2
A complex disorder of carbohydrate, fat and protein
metabolism that is primarily a result of a relative or
complete lack of insulin secretion by the beta cells of the
pancreas or of defects of the insulin receptors. Patients
with Type II are also further classified into further
categories of either Obese or Non Obese
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Imbalanced Nutrition: less
than body requirements
o Explain the
importance of
adequate nutrition
o Weigh the body
daily; monitor
results of lab tests
o Monitor blood
glucose levels
before every meal
o Administer insulin as
required
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Risk for injury related to GI
bleeding
o Examine stools and
emesis for gross and
occult blood
RISK FACTORS: metabolic syndrome, race, age, diet,
family history
Acute Kidney Failure
the rapid loss of the kidneys’ ability to remove waste and
help balance fluids and electrolytes in the body
RISK FACTORS: hospitalization, advanced age, diabetes,
blockages, high blood pressure, kidney disease, liver
Activity Intolerance/
o monitor vital signs
o encourage alternate
rest/activity to
provide exercise
without tiring
patient
Altered Nutrition: less than
body requirements
o Monitor and record
intake of protein,
iron and Vit C to
provide nutrients
needed for
hematopoiesis
o Suggest eating
smaller more
frequent meals to
increase dietary
intake
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Anemia tests
Iron level 4 (low)
Iron binding 88 (high)
Iron Sat’s 0.05 (low)
and full hematology profile
WBC 11.5 (high)
Hemoglobin 109 (low)
MCV 80 (low)
Red Cell Distribution 19.2
(high)
Neutrophils 9.58 (high)
Monocytes 1.15 (high)
Liver profile:
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AST 1668 (high)
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ALT 934 (high)
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GGTP 198 (high)
Troponin
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0.49 (high)
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Blood glucose monitoring
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patient’s blood glucose
sitting at 4.9, dropped from
6.3 steadily over the two
days I had her
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Occult blood stool test
o Patient was
constipated and
was not able to
supply stool
o
disease, heart failure
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CVA
Cerebrovascular accident (Stroke): an abnormal
condition of the brain characterized by occlusion by an
embolus, thrombus, or cerebrovascular hemorrhage or
vasospasm, resulting in ischemia of the brain tissues
normally perfused by the damaged vessels
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RISK FACTORS: age, race, gender, family history, high
blood pressure, smoking, diabetes
GERD
Gastro-Esophageal Reflux Disease: chronic disease
characterized by the reflux (backwards movement) of
stomach acid or sometimes bile into the esophagus.
When the signs and symptoms of acid reflux occur more
than twice a week or interfere with daily life, doctors
then diagnose GERD.
RISK FACTORS: Obesity; smoking; dry mouth; asthma;
diabetes; delayed stomach emptying
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Administer H2
receptor antagonists
(TUMS or other nonaluminum or
magnesium
antacids) as a
prophylaxis for
gastric stress ulcers
Risk for ineffective renal
perfusion
o Assess for signs of
decreased tissue
perfusion
o Assess for causative
factors related to
temporarily
impaired arterial
blood flow
o Monitor INR and PT
o Administer O2 as
needed
Infective Cerebral Tissue
Perfusion
o Maintain
usual/improved
level of
consciousness,
cognition, and
motor/sensory
function.
Risk for discomfort
o offer antacid relief
as needed
o eliminate acidic
foods from diet
Risk for electrolyte imbalance
o ensure proper
nutrition and fluid
intake
samples as
required during
my time with her
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Computed tomography
MRI
cerebral angiography
patient did not have these
tests during her stay at
NRGH, but would have had
these done when her CVA
occurred sometime prior to
her admittance
Barium X ray
Upper Endoscopy
pH test
tests indicated high levels
of erosion in upper GI tract,
and pH levels indicative of
excessive gastric secretions
Osteoarthritis (OA or
Degenerative Arthritis)
a joint inflammation that results from cartilage
degeneration.
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RISK FACTORS: gender, age, bone deformities, joint
injuries, obesity, certain diseases, certain occupations
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Impaired physical mobility
o assist in movements
that involve major
joints and large
muscle movements
such as standing,
sitting and reaching
Self-Care deficit
o Assist in personal
care when required.
o Provide cleaning
supplies and items
on bedside table
and close to patient
for ease of access.
o provide call bell for
patient to seek help
when required
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Anti CCP test
X-Rays
These tests were not
performed during the
client’s stay in the hospital
Medications
Prednisone
Class: therapeutic antiasthmatic
Dose/Route: 25 mg
PO
Drug Interactions:
thiazide and loop
diuretics, digoxin
Indications
Used systemically in inflammatory, allergic,
hematologic, neoplastic and autoimmune disorders
(Used for COPD for this patient)
Contraindications/Side Effects
Use cautiously in chronic treatment. Avoid in known alcohol, bisulfite
and tartrazine hypersensitivity
Depression, euphoria, headache, increased intracranial pressure,
hypertension, anorexia, nausea, acne, muscle wasting, osteoporosis,
Domperidone
Class: antidopaminergic/
antiemetic
Dose/Route: 10 mg PO
QID
Drug Interactions:
For management of dyspepsia, heartburn, epigastric
pain, nausea, and vomiting.
Side effects include galactorrhea, gynecomastia, or menstrual
irregularities.
Fluticasone-Salmeterol
Class: corticosteroid
Dose/Route: 250-500
mcg BID nebulizer
Drug Interactions:
Ketoconazole, Ritonavir,
clarithromycin,
erythromycin
used in the management of asthma and chronic
obstructive pulmonary disease
Candidiasis
Headache, dysphonia, hoarseness, bronchospasms, cough, wheezing,
adrenal suppression
Clopidogrel
Class: antiplatelet agent
Dose/Route: 75 mg PO
Drug Interactions:
aspirin, NSAIDs, heparin,
warfarin, thrombolytic
agents, phenytoin,
fluvostatin
Reduction of atherosclerotic events (MI, stroke,
vascular death)
Depression, dizziness, fatigue, headache, cough, dyspnea, bleeding,
neutropenia
Paroxetine
Class: anti-anxiety
Dose/Route: 20mg PO
Drug Interactions:
MAOIs, cimetidine,
digoxin, NSAIDs,
tramadol
Major depressive or panic disorders
Anxiety, dizziness, drowsiness, headache, insomnia, weakness,
respiratory disorders, constipation, diarrhea, dry mouth, nausea,
sweating
Levothyroxine
Class: hormones
Dose/Route: 150 mcg
PO daily
Drug Interactions:
Bile acid sequestrants.
May increase effects of
Warfarin, May increase
insulin requirements in
diabetes, Increased CV
effects with adrenergics.
Prescribed to help increase thyroid activity.
Should not be used with calcium, iron, magnesium or zinc
supplements
Pantoprazole
Magnesium
Class: proton pump
inhibitor
Dose/Route: 40 mg PO
BID
Drug Interactions:
warfarin and drugs
requiring acid pH
Reduces acid secretions in stomach. Used to treat
erosive esophagitis associated with GERD
Hypersensitivity, headache, abdominal pain, diarrhea, flatulence,
eructation
Insulin lispro
Class: insulin
Dose/Route:
supplemental SubQ QID
and AM/Supper
Drug Interactions:
Diabetes- fast acting insulin
Insulin isophane NPH
Class: insulin
Dose/Route: SubQ
AM/Supper QID
Drug Interactions:
Diabetes- regular insulin
Metoprolol
Class: anti-anginal
Dose/Route: PO
Drug Interactions:
general anaesthesia, IV
phenytoin, verapamil,
concurrent use with
ephedrine, cocaine,
amphetamines,
epinephrine, MAOIs
Ipatropium nebulizer
(Atrovent)
Class: bronchodilator
Dose/Route: nebulizer
Drug Interactions:
Hypertension, angina pectoris, prevention of MI,
management of class II or III heart failure.
Iron Gluconate
Class: iron
Dose/Route: 300 mg PO
Drug Interactions:
dimercaprol
Hypochromic anaemia
Uncompensated CHF, pulmonary edema, cardiogenic shock,
bradycardia, heart block
Fatigue, weakness, constipation, blurred vision, wheezing,
bradycardia, CHF, pulmonary edema
COPD, asthma
Dehydration, low BP, fast and weak pulse, shock, nausea, vomiting
blood, dizziness, coma, convulsions, skin flushing
Dalteparin
Class: blood thinner
Dose/Route: 5000 IU
SubQ Q24hr
Drug Interactions:
Drugs that affect
platelet function and
coagulation incl.
warfarin, aspirin,
NSAIDs, clopidogrel, and
thrombolytics
PRNs
Ipatropium
Hypertension, CHF: prevention of venous
thromboembolisms
Ventolin
Diarol
bronchodilator
Anti-hyperglycemic
Indications
bronchodilator
Dizziness, headache, insomnia, edema, constipation, nausea,
vomiting, urinary retention, anemia
Contraindications/Side Effects
Dizziness, headache, nervousness, blurred vision, sore throat,
bronchospasm, cough, hypotension, palpitations