Question

Mr. A., a 67 year old African American male is here at the clinic for medication refill and annual physical exam. He doesn't remember all of his meds since he didn't write them down, but he remebers taking St. John's Wort over the counter, ASA 81mg daily, Digoxin 0.125mg daily. He has a history of Rheumatic Heart Disease, Mitral valve replacement with mechanical device, and heart failure. He reported today that he has been feeling easily tired today. He has 2+ pitting edema in both legs. He also c/o pain when he walks but the pain subsides when he stopped working. The doctor just gave him an order for outpatient Chest xray. In the meantime, the doctor examined the patient and found the following:
VS--96.8, 24, 66, 136/88, sats on RA--90%; crackles bilateral lower lobes, 2+ edema of the legs,
abd tenderness, and dyspnea with exertion. Lower 1/3 of lower legs are shiny, cool to touch, and hairless w/ dark discoloration

make a care plan with 4 subjective and objective data and also 6 interventions

Answer 1

1. CARE PLAN -1 Acute pain

Assessment:-

Subjective data:- patient says that he is having chest pain on exertion

Objective data:- patient exhibited facial expressions of pain assessed by pain rating scale ( for eg. Rate-7)

Nursing diagnosis:- Acute pain (chest pain) related to arthralgia secondary to rheumatoid heart disease as evidenced by verbal communication and pain rating scale.

Planning:- patient will demonstrate normal body functioning without pain

Interventions:-

• Assess the patient's pain level.
• Provide proper position and allow rest
• Ask the patient to avoid exertional activities which exaggerate pain
• Administer medications like salicylates ( aspirin) which helps to reduce pain and anti-inflammatory medications.
• Provide relaxation techniques like meditation
• Educate patient and relatives regarding the importance of medication administration and positioning

2. CARE PLAN -2 Excess fluid volume

Assessment:-

Subjective data:- patient says that " I'm having edema on my legs"

Objective data:- patient is having pitting edema on legs (+2 pitting edema)

Nursing diagnosis:- Excess fluid volume related to reduced glomerular filtration rate secondary to heart failure as evidenced by putting edema and abnormal breath sounds ( crackles)

Planning:- Demonstrate normal fluid volume and clear breath sounds.

Interventions:-

• Assess the weight daily
• Monitor intake output daily
• Position the patient
• Follow low sodium diet or fluid restrictions
• Auscultate the breath sounds for any abnormalities
• Administer diuretics ( diuretics or potassium sparing diuretics)
• Educate the patient about activities, diet and medication

3. CARE PLAN -3 Ineffective breathing pattern

Assessment:-

Subjective data:- patient says that " I'm having breathing difficulty on exertion"

Objective data :- patient exhibits breathing difficulty while working.

Nursing diagnosis:- Ineffective breathing pattern related to heart disease as eveidenced by dyspnea

Interventions:-

• Assess the breathing pattern of the patient
• Monitor respiratory rate
• Provide positioning ( semi- Fowler's or high Fowler's position)
• Administer oxygen therapy if needed
• Educate relaxation techniques
• Educate the patient to avoid excertional activities

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