Care Plan for Cardiology Patient
Patient Initials:I.A.M Age: 52 Gender: Male
Subjective Data
Chief Compliant: “I have experienced lightheadedness, palpitations, and shortness of breath (2/7)”
History of Present Illness: The onsets of the palpitation, shortness of breath and lightheadedness was two days ago. The symptoms aggravated with activity. Initially, rest was sufficient to relieve the symptoms, but for the past two days, this has not been the case.
PMH/Medical/Surgical History: He is a known hypertensive (10years) with hyperlipidemia for 5years and has had a stent placement two weeks ago. The patient also had rheumatic heart disease (mitral valve) as a child. He is on Lisinopril 20 mg PO QD for the inhibition ACE which is necessary for causing an increase in blood pressure, Furosemide 20 mg PO QD for the reduction of sodium ion reabsorption that increases the blood pressure and Gemfibrozil 600 mg PO BID for the lowering of serum lipid level, which he reports maximal adherence. Moreover, he has no known drug allergy. The patient has been hospitalized before for a surgical procedure of stent placement (14/7).
Significant Family History: Patient has no significant family history that is contributory to the current symptoms or illness.
Social History: He reports that he quitted smoking five years ago and after 20 years of smoking. He has also been adhering to the low-fat diet for the past two years. Besides, he asserts that he walks two miles a day and rides the bicycle thrice a week as part of his exercise regime.
Review of Symptoms: Patient denies having any problems relating to all the body systems.
Objective Data:
Vital Signs: BP -160/90 due to hypertension (Normal ranges 110/70 to 135/90mm/Hg ) ; P- 146b/min (Normal range between 60-100b/min) ; R- 22 (Normal range between 16-24 breaths/min); T- 98.6F (Normal range between 97.8F and 99F); Wt.-254; Ht.- 5′ 7″; BMI- 39.77kg/m2 suggests that he is obese (Normal range between 16.5-24.5kg/m2)
Physical Assessment Findings:
HEENT: The pupils are equal round and reactive to light, and the accommodation is ok. The jugular vein is not distended. The patient, however, has mild Atria-ventricular nicking indicative of hypertension.
Lymph Nodes: Not enlarged
Carotids: No significant observation
Lungs: All landmarks are clear upon auscultation
Heart: The patient has an irregular rate, with the absence murmurs or gallops
Abdomen: It is soft, non-tender with active bowel sounds
Genital/Pelvic: The patient requested not to be examined.
Rectum: Normal
Extremities/Pulses: No notable edema with normal pulses throughout
Neurologic: He is well oriented to time, person and place
Laboratory and Diagnostic Test Results
Na – 136 Within the normal range (135-145) –essential for determining a kidney complication after stent placement
K – 4.5 Within the normal range (3.5-5.0) –essential for determining a kidney complication after stent placement
Cl – 97 Within the normal range (96-106) –essential for determining a kidney complication after stent placement
BUN – 20 Within the normal range (3-20) –essential for determining a kidney complication after stent placement
Cr – 1.2 Within the normal range (0.6-2) –essential for determining a kidney complication after stent placement
Total Cholesterol – 240 High since the standard is below 200mg/dl
Triglycerides – 180 Borderline high since the standard is less than 150mg/dl
INR – 1.1 Normal since it is within the normal range (less than or equal to 1.1)
Chest X-ray – Clear
ECG – Atrial Fibrillation which is responsible, no P waves, variable R-R interval normal QRS
Assessment
The patient’s likely diagnoses include but not limited to:
- Atrial fibrillation (I48.91) as evidenced by the ECG reading and the chief complaints (lightheadedness, and palpitations)
- Hypertension (code I10) as shown by the high blood pressure reading (160/90mm/Hg)
- Obesity (code E66.9) as evidenced by the high BMI (39.77kg/m2) (Centers for Medicare & Medicaid Services, 2016)
Plan of Care:
Firstly, the patient is a likely candidate for Atrial Fibrillation given the ECG reading and the chief complaints (lightheadedness, and palpitations). His plan of care on this diagnosis of Atrial Fibrillation must include a diagnostic test such as a repeat ECG to ascertain the particular type of this dysrhythmia. Such clarity will enable one to take the right course of action (Kitchens, 2015). The therapeutic management must include heart rate controlling drugs such as will carvedilol, which block the Beta-adrenergic cells. Also, administering calcium channel blockers such as nifedipine offer the best outcome for such patients. Besides, anticoagulants are essential for preventing blood clots whose effect is disastrous. On this plan, the nurse must also emphasize the side effects of drugs (Winkelman, Ignatavicius, Workman, & Ignatavicius, 2013). For instance, the patient must know signs of bleeding due to taking anticoagulant medication.
Secondly, the patient is a candidate of hypertension due to a high blood pressure reading (160/90mm/Hg) and the AV nicking. The test that one can use to confirm this diagnosis is the blood pressure measurement. The therapeutic management must assess the effectiveness of the antihypertensive medications he is using to determine the next course of action concerning medical management. The nurse must also emphasize the need for maintenance of a healthy lifestyle that considers exercise and diet low in sodium and fats to control the blood pressure maximally. In this diagnosis, the plan of care should involve the patient throughout the care and interventions like patient teaching sessions for lifestyle changes and drug adherence (Bunker, 2014).
Lastly, obesity is another likely diagnosis given the high BMI of the patient (39.77kg/m2). To diagnose this condition, measurement of the weight and height are essential for the final calculation of the BMI that depicts whether one is obese or not. Laboratory tests of determining of body fats are also useful for making this diagnosis. For one to lower the body fat content, a change in the lifestyle is essential. Such a change comprises eating food with less fat and utilization of exercises. Patient education on lifestyle modification is thus necessary (Lazarou & Kouta, 2010). Actions like this will break down the fat content and reduce the harsh effects posed by this condition.
References
Bunker, J. (2014). Hypertension: diagnosis, assessment and management. Nursing Standard, 28(42), 50-59. http://dx.doi.org/10.7748/ns.28.42.50.e8682
Centers for Medicare & Medicaid Services,. (2016). Medicare Coverage Database – Centers for Medicare & Medicaid Services. Cms.gov. Retrieved 23 November 2016, from https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?KeyWord=hypertension&bc=AAAAAAAAAAAQAA%3d%3d&
Kitchens, J. (2015). Heart Failure, An Issue of Critical Nursing Clinics(1st ed.). Philadelphia: Elsevier Health Sciences.
Lazarou, C. & Kouta, C. (2010). The role of nurses in the prevention and management of obesity. British Journal Of Nursing, 19(10), 641-647. http://dx.doi.org/10.12968/bjon.2010.19.10.48203
Winkelman, C., Ignatavicius, D., Workman, M., & Ignatavicius, D. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing (1st ed.). St. Louis, MO: Elsevier Saunders.
