Daryl Apostol
1. Impaired gas exchange
 O2 sat & on 1-2 L/min
adventitious lung sounds- fine
crackles at bilateral lung bases
 H&H
SOB
Dyspnea
Non-productive cough
Dizziness & light-headedness
Fatigue
Monitor CBCs & ABGs levels
On Albuterol, Spiriva, & Atrovent
7. Infection
Wet non-productive cough
Abnormal sputum Cx – C. albicans
Fever
Fatigue
Mild  WBCs
Taking IV Levaquin BID
Deep breathing
Chief medical Dx:
Exacerbation of CHF
2. Abnormal ECG/EKG
a-fib with rapid ventricular
response
RVR 125 bpm
Possible anterior infarction
Continuous tele monitoring
On Eliquis for a-fib
Priority Assessments:
O2 sat, activity tolerance, tele
monitoring, BP, HR, RR, daily Wt,
and perfusion (peripheral edema)
6. Inadequate nutrition intake
SOB
Fatigue
Dyspnea
Activity intolerance
Cough
Regular diet plan
5. CO
CHF
a-fib
HTN
Chest pain
SOB
Activity Intolerance
Taking Lisinopril & Metoprolol
3. Abnormal CXR
Mild interstitial markings
Minimal infiltrate at rt. mid lung
Minimal pleural effusion
Continuous O2 sat monitoring
O2 supplement at 1-2 L/min
Taking Spironolactone
4. Activity Intolerance
 O2 sat
Muscle weakness
Unsteady gait
HR
BP
 activity tolerance
Reduce bilateral LE edema
Daryl Apostol
Desired Outcomes
Impaired gas exchange
1. The patient will be able to breath on room air by end
of shift
2. O2 sat will be above 90% on room air
3. Patient will not have c/o dyspnea & SOB
Abnormal ECG/ EKG
1. Patient will have controlled heart function
Abnormal CXR
1. Patient will have normal CXR results after
completion of antibiotic therapy
Activity Intolerance
1. Progression of activity tolerance by day 3
2. No complaints of SOB, chest pain, dyspnea, llight-headedness,
and dizziness
Decreased CO
1. Patient will be able tolerate activity w/o difficulties
2. O2 sat will stay above 90% w/wo O2 supplement by
end of shift
Inadequate Nutrition intake
1. Patient will obtain adequate nutrition intake after
the second day on antibiotic therapy
Infection
1. Patient will not have S/S of infection after
completion of antibiotic therapy
Inerventions
Impaired gas exchange
1. Monitor patient’s O2 sat at rest and during activity
2. Continuous monitoring of patient’s O2 sat
3. Assess for c/o dyspnea & SOB, abnormal breathing pattern &
status
4. Monitor CBCs & ABGs
Abnormal ECG/EKG
1. Continuous tele monitoring
2. Administer heart medications as ordered
Abnormal CXR
1. Administer antibiotics & diuretic medications as ordered
2. Educate patient on deep breathing techniques to remove mucus
from lungs
Activity Intolerance
1. Ambulate patient after respiratory medications have been given
2. Monitor for S/S of activity intolerance
Decreased CO
1. Monitor BP and P
2. Monitor breathing pattern and O2 sat
3. O2 supplement PRN
4. Continuous O2 sat monitoring
Inadequate Nutrition intake
1. Monitor patient’s intake
2. Monitor for S/S activity intolerance
3. Follow diet plan
Infection
1. Monitor for S/S of infection
2. Administer antibiotics as ordered
3. Obtain sputum Cx
4. Deep breathing & coughing out mucus
5. Adequate nutrition intake
Daryl Apostol
Evaluation
During my evaluation in which I had only two days to evaluate my patient, I planned to measure each desired outcome
by constant monitoring and intermittent assessments.
For all of the outcomes except for CXR and ECG, which have already been obtained, I will obtain a baseline reading on
O2 sat, VS, and assess for S/S of infection, activity tolerance, and amount of intake. Once I have completed that portion, I will
begin my evaluation process of each outcome individually.
For Outcome one, I will assess lung sounds, breathing pattern, and continuous O2 sat, and what liter of oxygen patient is
on. I will then decrease the liter of oxygen by half then check on patient in every fifteen minutes to reassess patient and see
how he is tolerating the decrease in liter of oxygen. I will also take note of what patient has been doing during each fifteenminute increment. I will then document my findings on the flow sheet to track progress. After checking on patient every fifteen
minutes for an hour, I will continue to monitor patient’s breathing status as part of my hourly roundings to prevent injuring
patient.
For Outcome two, I will monitor the tele-monitor for changes in the PVC waves then comparing that to my initial shift
assessment and from the last shift’s findings. I will administer patient’s scheduled blood thinner to prevent clot formation and
Daryl Apostol
blood pressure medications as ordered. I will include in my plan of care, minimal activities that will not exacerbate his CHF
even more.
For outcome three, I will administer patient’s antibiotic treatment twice daily as ordered, assess and monitor for S/S of
infection, and practice deep breathing techniques with patient to strengthen lungs so that patient is able to cough out mucus. A
sputum culture will be obtained prior to starting antibiotic treatment to verify the type of infection and assure the right
medication is given. After 24 hours on the correct treatment, patient will be followed up on to reassess for S/S of ongoing
infection. Patient will be educated on S/S to observe to identify worsening of infection or if treatment is not working. I will
inform MD to order another CXR after completion of therapy to confirm that infection has cleared.
For Outcome four, I will first asses patient’s breathing pattern, O2 sat, lung sounds, and asses for c/o of dyspnea, SOB,
and chest pain. Before getting patient out of bed to assess level of energy and toleration of activity, I will verify that RT has
administered patient’s respiratory medications. I will attach a portable O2 sat monitor and a portable O2 tank. I will then
assess, gait, S/S of breathing status, and asses for dizziness and light-headedness. I then will document my findings. Later in
the shift I will consult with PT to obtain her findings of patient’s activity level and compare it to that of my earlier activity to
identify if there has been an progression in activity tolerance.
Daryl Apostol
For Outcome five, I will have continuous O2 sat monitoring and tele-monitoring, administer heart medications as well as
diuretics, and assess for any breathing problems. I will incorporate patient’s activity results as well as PT’s findings into my
evaluation for progression of activity tolerance and the results on the tele-monitor.
For Outcome six, I will check that RT has administered morning dose of patient’s respiratory medications and assess
eating status during breakfast. I will then document amount of food eaten and reassess patient’s breathing status, O2 sat while
eating, and energy level. After completion of his breakfast, I will assess patient for c/o SOB and dyspnea if that may have
occurred while eating. I will also assess again during and after lunch. I then will compare those findings to his results from
night shift’s findings during his dinner meal.
For outcome seven, I will assess for S/S of infection, administer scheduled antibiotics, review culture results and CXR
results. I will reassess patient right before the ending of the shift to identify if patient is feeling better and if his energy level
has progressed. I will also monitor coughing quality and obtain another sputum culture as ordered. I will educate patient on
how to identify S/S of infection and the side effects of his infection treatment. I will stay with patient to see if patient is
tolerating medication via IV and that there is no reaction to the medication and also to follow up with patient after about 24
hours on treatment and reassess patient’s symptoms to verify if treatment is working.
Daryl Apostol
Discharge Planning/Teaching
Upon evaluation of the desired outcomes above and the level of progression of patient’s health and activity, I feel that
patient will need home oxygen therapy and a support system that will assist patient with some of his ADLs, which will mostly
be bathing, in which he will need only partial assistance with, and to assure that he is compliant with his medication regimen.
Patient stated that two of his daughters, one of which he lives with will be support system. He will also need handrails installed
in the bathroom and a slip-proof mat. Everything should be in close proximity to prevent using too much of his energy. I
recommend a room closer to the bathroom or switching bedroom to the first floor if house is a two-story. He will also need a
four-wheel walker to assist with long distance walking. I also highly recommend that patient wear a emergency alert bracelet,
and most importantly stop driving.
Patient has been informed of the requirements needed to be discharge and what he will go home with. Patient
verbalizes his understanding and prefers to start discharge teaching when his daughters are present. Teaching will include
home O2 therapy and care, living situations, medication regimen and compliance, and minimizing activity levels to prevent
another exacerbation of CHF. Daughters will be given information to the supply facility that will provide the oxygen tank and
supply, as well as O2 tank refills when needed. The social worker will collaborate with the medical supply facility to begin prior
authorization paperwork to patient’s insurance company for home oxygen therapy and supplies and also for a four-wheel
Daryl Apostol
walker. Orders to install handrails in the home will be obtained as well as a referral to a pulmonologist for ongoing respiratory
monitoring will be made.