DEPARTMENT OF NURSING

Nursing Care Plan

Student Name: Kathleen Willis Age: 89

Course number: 281-601 Developmental state: Integrity vs Despair/Later Maturity
Health care agency: Holy Name Hospital Instructor: Marites Alconis
Date of Care: 09/20/2020
Patient’s initials: AK
Patient’s room: 127 bed 1

Medical diagnosis: EXPLAIN PATHOPHYSIOLOGY AND INCLUDE STRUCTURAL FUNCTIONAL CHANGES THAT THE DISEASE CAUSES:
Patient’s medical dx is aortic stenosis. Aortic stenosis is classified as the narrowing of the opening of the aortic valves which obstructs blood flow from the left
ventricle to the ascending aorta during systole. Progression of aortic stenosis leads to pressure overload causing compensatory left ventricle hypertrophy, diastolic
dysfunction, an increase in left atrial size and/or the development of mitral and tricuspid regurgitation.

Explain significance of operative procedure, lab data, and/or special diagnostic test or procedures:

Pts significant lab data:

INR: 3.1 (2.0-3.0)- The international normalized ratio. A prothrombin test measures how quickly blood clots. Patient is on Warfarin so pt result is expressed as a
ratio. Patient’s lab data suggests her blood is clotting more slowly than desired and that her dose of Warfarin should be withheld which was ordered by her
physician.
Hemoglobin: 9.9 (12.1-15.1)- protein component of red blood cells which is responsible for transferring oxygen from the lungs to the rest of the body
Hematocrit: 31 (36-48)- the ratio of the volume of red blood cells to the total volume of blood
My patient’s H/H levels are significant because Warfarin reduces the risk of thromboembolic events but can create an increased risk of bleeding. Anemia
can occur during warfarin therapy and is a predictor of bleeding and thrombotic complications in patients with atrial fibrillation who are on warfarin. Pt’s physician
ordered an iron infusion.
Glucose: 134 (70-99) Pt is a type 2 diabetic. In type 2 diabetes pt’s bodies either resist the effects of insulin or don’t produce enough insulin. Patient’s physician
ordered insulin only if glucose was over 180.
Diagnostic tests:
Pt had a CT scan without contrast of her right hip. Preliminary results showed an intramuscular hematoma in the right inguinal region involving the hip flexor.

Instructor’s comments:
ASSESSMENT NURSING DIAGNOSIS
Universal Self Problem, Etiology, GOALS PLANNING SCIENTIFIC RATIONALES EVALUATION
Care Requisites Symptoms INTERVENTIONS
Self Care Agency (SCA): Patient will display 1. Assess for and document: 1. Reduced cardiac output 1. Patient’s vitals
Pt currently lives with adequate cardiac output as Lung sounds can present itself among remained stable. Lung
daughter however will be P: Decreased cardiac evidenced by an ability to Heart sounds vital signs. Lung sounds sounds were clear. A
discharged to a skilled output tolerate activity without Blood pressure should be clear however soft systolic murmur
rehabilitation and nursing symptoms of syncope by Heart rate a finding of crackles was heard between s1
facility. Patient is able to discharge Urine output indicate fluid buildup. and s2. Blood pressure
communicate her needs Mental status Certain heart sounds can and heart rate were
clearly with her family. q 4 hours if stable q2 if unstable indicate failure of different within normal limits.
E: related to irregular s1- parts of the heart. S3 Urine output within
s2 rhythm with soft 2. Examine lab data: indicates a reduced left normal limits and
Self Care Deficit (SCD) murmur Electrolytes ventricular ejection. Many mental status was also
SCD’s: CBC patients have within normal limits.
-Decreased strength and Creatinine compensatory 2. Lab data was within
endurance PT/INR tachycardia and low normal limits with the
-Pain from osteoarthritis in q shift blood pressure in exception of PT/INR.
both knees response to reduced INR was slightly
- Voids with difficulty. S: as evidenced by 2 3. Administer medications as cardiac output. The renal elevated and pt’s
Requires foley catheter syncopal episodes prescribed noting effects and system counterbalances physician ordered a
toxicity q shift low blood pressure by hold on her next dose
retaining water so it is of warfarin.
Nursing agency: 4. Assess for pain on a scale of 1- imperative to check urine 3. All medications were
Partially compensatory due to 10 and provide pain output. Lastly, noting any given as prescribed.
need for ambulation, management q 4 hours changes in mental status Lab data suggests no
assistance in dressing and is important as decreased toxicities present.
hygiene, and need for foley cerebral perfusion are 4. Patient complained of
catheter, however pt can feed 5. Position for optimal venous typically reflected in pain at a 5 and was
herself return q shift irritability and administered
restlessness. acetaminophen 650mg
Subjective Data: Pain in 2. Patient’s blood work can as prescribed.
knees, lightheadedness provide insight as to why 5. Patient was positioned
there is a decreased in semi-flowers with the
Objective Data: cardiac output. Low head of the bed at a 30
 sodium levels are often degree angle with the
Vital signs: present in late stage exception of when her
Temp: 97.0 heart failure. Creatinine food arrived pt sat at a
RR: 18 levels will increase in 45 degree angle
BP: 138/71 patient’s with heart failure
Pulse: 96 because of decreased
O2: 98% on room air perfusion to the kidneys.
(normal) Potassium is another
electrolyte that must be
Labs: monitored in patients with
decreased cardiac output.
INR: 3.1 Potassium affects the
Magnesium: 1.5 way heart muscles work
WBC: 6.2 and too much of it may
RBC: 3.42 cause a myocardial
Hemoglobin: 9.9 infarction. Low potassium
Hematocrit: 31 levels alter the flow of
Platelets: 251 blood throughout the
Neutrophils: 68 heart and may cause
Lymphocytes: 19 palpitations or arrythmias.
Glucose: 134 My patient is on warfarin
Sodium: 135 therefore PT/INR values
Potassium: 4.2 are a crucial part of a
Blood Urea Nitrogen: 9 treatment plan. Too little
Creatinine: 0.65 INR will leave risk for a
blood clot and too high of
CT of Right Hip: INR means the body
Intramuscular hematoma in takes longer to clot and
right inguinal region involving there is an increased risk
the hip flexor measures 4.0 x for bleeding.
4.6 x 7.3 cm 3. Administration of patient’s
medications as
Chest Xray: Clear prescribed is crucial for
the patient’s health. Too
much of certain drugs
such as diuretics,
antidysrhythmics,
 angiotensin-converting
enzyme inhibitors or
vasodilators can cause
toxicities in the body
leading to further
decreased output.
4. Chest pain is suggestive
of an inadequate blood
supply to the heart, which
can compromise cardiac
output.
5. Placing patient in a
supine or semi-fowlers
position will allow for
maximum chest
expansion

References

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer.

Prothrombin time test. (2018, November 06). Retrieved September 27, 2020, from https://www.mayoclinic.org/tests-procedures/prothrombin-time/about/pac-20384661
Wayne, G., By, -, Wayne, G., & Gil Wayne graduated in 2008 with a bachelor of science in nursing and during the same year. (2019, January 29). Decreased Cardiac Output –

Nursing Diagnosis & Care Plan. Retrieved September 27, 2020, from https://nurseslabs.com/decreased-cardiac-output/