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CHF Concept Map

This document contains information about a patient named Jennifer Bartold who was admitted with congestive heart failure and coronary artery disease. She has a history of multiple medical issues including low ejection fraction, hypertension, prostate cancer, kidney disease, and dementia. Her medications and treatment plan are listed, along with abnormal lab values and nursing care instructions focusing on monitoring, mobility, education, and discharge planning.

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Christy Wegner Cooper
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17K vistas1 página

CHF Concept Map

This document contains information about a patient named Jennifer Bartold who was admitted with congestive heart failure and coronary artery disease. She has a history of multiple medical issues including low ejection fraction, hypertension, prostate cancer, kidney disease, and dementia. Her medications and treatment plan are listed, along with abnormal lab values and nursing care instructions focusing on monitoring, mobility, education, and discharge planning.

Cargado por

Christy Wegner Cooper
Derechos de autor
© Attribution Non-Commercial (BY-NC)
Nos tomamos en serio los derechos de los contenidos. Si sospechas que se trata de tu contenido, reclámalo aquí.
Formatos disponibles
Descarga como DOCX, PDF, TXT o lee en línea desde Scribd
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Jennifer Bartold

HPI/Diseases:
 CHF with EF 23%
 Diastolic HTN
Pathophysiology  Prostate Cancer (prostatectomy)
CHF: The myocardial Admitting Diagnosis:  CAD with ischemic cardiomyopathy
tissue becomes damaged  CHF Systolic Heart Failure  Hyperlipidemia
and cannot generate an  CAD (coronary artery disease)  CKD (chronic kidney disease)
adequate cardiac output to  IVCD placement (intraventricular conduction
device) because of CAD
perfuse vital tissues. If the
left ventricle is damaged,  Dementia
pulmonary congestion can
result. [ CITATION

Medication
Aspirin enteric coated 81 mg PO daily Cardio disease
Heparin Sodium SubQ 5,000 units q8h DVT prophylaxis
Furosemide Lasix 40mg IVP BID Diuresis
Simvastin 40 mg PO hs Hyperlipidemia
Nursing Care Room: 17B Acetaminophen 650 mg PO q6h prn Fever & pain
Patient: EL, Male, AA Albuterol Inhaler 4 puff q4h prn SOB
 Vital signs q4h
Age: 76 yo (7/22/33) Bisacodyl Tablet EC 10mg PO BID prn Constipation
 Monitor telemetry
Allergy: NKA Docusate Sodium 100 mg PO prn daily Constipation
 Foley present –measure I&O (notify MD Weight/height: 139.4 lbs; 76 inches Guaifenesin Liquid 10 mL PO q4h prn Cough
if urine output <300 mL in 8 hours) Code status: Full code Prochlorperazine 5-10 mg IVP q6h prn N/V
 Weigh daily @ 5AM Advanced directive: @ home
 Peripheral IV: right FA, 20 gauge Resident: Orange, Roy (407-3686)
 Activity as tolerated (fall risk)-use walker Admit: 6/22/2010
 Patient has low boy bed Chief Complaint: SOB, dyspnea
 Patient has impaired memory Precautions: Fall Risk
(dementia)
Diet Labs/Diagnostics
 2 gram Na Diet  Chest 1 view X ray portable –Active
 Ensure- Strawberry TID w/meals -1 can order
Nursing Dx:
 Activity intolerance Abnormal Lab Values
 Decreased cardiac output
Psychosocial Hx:
 Father –MI →deceased RDW 18.2 (11.8-14.6)
 Risk for falls HgB 11.7 (13.8-17.2)
Education Social Hx:
HCT 36.7 (40.7-50.3%)
 Involve patient’s brother (Ronald)  Single
B type natriuretic 3401 (0-100)
 Teach about proper diet  Retired police officer peptide
 Teach about fall risk  Brother (Ronald) is present CO2 total 18 (22-32)
Discharge  Baptist BUN 57 (8-25)
 Hx of cigarette use(quit), no Creatine 2.37 (0.70-1.30)
etOH AST 58 (11-47)

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