PLAN OF CARE IHUMAN PATIENT ASSESSMENT
STUDENT: Date of Care: 3/27/2021
Age: 69 Gender: M
Resuscitation Status Allergies none
Reason for
... [Show More] Admission: Heart Failure Exacerbation
Medical Diagnoses: stage II right sided heart failure
Surgeries/Procedures and Dates:
Past medical history Coronary artery disease, Hyperlipidemia, Myocardial infarction, Hypertension, Stage 2 Right sided Heart failure
Current Orders:
Diet_low sodium (2 grams) diet; 2 liter fluid restriction _ Activity OOB with assistance
Intake _N/A Output N/A Accu Cheks Vital signs. BP:126/72, Pulse:78/min, Tempt: 98.6F, Respiration:16/min, oxygen sat:98% on room air, Pain 0/10Drsg changes/wound
care Foley N/A NG/G-tube/PEG?PEJ N/A
IV right arm lower arm antecubital space Reason for IV normal saline 0.9%) 5MI IV
Other orders:
SCDs to bilateral lower extremities when not ambulating
Titrate to keep O2 saturation above 92%
weigh the patient every morning at the same time
Most recent Imaging Findings: (CXR? CT? MRI?)
Type of Imaging (X-Ray, CT, MRI,
etc) Body Area Imaged Reason for testing and results of test
x-ray AP Chest To view anatomy of lungs; Cardiomegaly and intestinal pulmonary edema
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date Lab Test Results Norms Comments
Lipid profile serum Cholesterol – 208
HDL- 45 LDL-115
Triglycerides- 129 Cholesterol – < 200 HDL- >45 LDL- < 100
Triglycerides- < 150 High levels of cholesterol,
triglyceride, LDL; put at risk for heart dieases
CBC All normal N/a Normal
BMP All normal n/a Normal
aPPT 30 secs 25-35 Normal
PT 12 secs 11-15 Normal
INR 1.1 0.8-1.1 Normal
Magnesium, serum 1.9 1.3-2.1 Normal
Phosphorus, serum 4.4 2.5-4.6 Normal
BNP 5.1 <3.1 High BNP; more likely heart failure
Other recent, significant procedures or tests (EKG, etc)
Date Test Reason for testing and results of test
12 lead ECG To assess the electrical activity of the heart. Result pending
TTE Ultrasound test of the heart. Result pending
Based on the information on these pages and your assessment of this patient, what is your FIRST or PRIORITY concern and why?
Decrease cardiac output - The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness, and paleness. [Show Less]