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Please write a detailed nursing care plan for a 73 year old white male with the initials of J.D. He has end stage
Congestive Heart failure, but his reason for hospitalization is due to shortness of breath with minimal excretion
possibly caused by pleural effusion. He also has lower and upper extremity Anasarca. He has no known drug
allergies and his medication list is as follows:
Enalapril 2.5mg PO, daily.
Levothyroxine 0.05mg PO, daily.
Pantoprazole 40mg PO daily.
Multi vitamin 1 TAB PO daily.
Digoxin 0.125 PO daily.
Ferrous Sulfate 325mg PO daily.
Magnesium Oxide 400mg PO daily.
Metoprolol Tartrate 12.5mg PO daily.
Simvastatin 20mg PO daily.
Warfarin 2.5mg PO daily.
Bacitracin ointment to a skin ulcers of the lower left leg and of the right arm.
Acetaminophen 325mg PO, Q4H/PRN.
He appears very weak and wasting. He has progressive confusion due to a possible mass on his brain and he has
server edema below his hips and in his arms.
Chest x-ray chows a possible lung nodule and effusion post thoracentesis. Head ct shows lesion in right
cerebellum-met vs blood.
No chest pain, palpitations, dizziness or H/A.
He has a significant cardiac hx. He has a longstanding hx of cardiacmyopathy, which is probably a combination of
obesity-related as well as alcohol as he was a former alcoholic. He has a hx of morbid obesity and food addition.
He has a hx of chronic A-fib. Hx of server right heart failure. In the past he had monomorphic V-tach which was
sustained and he received a pacemaker. He has significant lower extremity edema due to right sided heart failure.
He has difficulty sleeping flat and often sleeps in a chair. He never had MI although he has cardiomyopathy.
VITAL SIGNS:
BP: 84.52 Pulse: 68 Resp: 24 Spo2: 97% NC, 2LPM Temp: 98.1 oral Pain: 2/10
LAB Chemistry:
Sodium (136-145 MMOL/L) 142
Potassium (3.5-51 MMOL/L) 4.7
Chloride (90-107 MMOL/L) 103
C02 (21-32 MMOL/L) 30
BUN (7-18 MG/DL) 70
Creatinine (0.7-1.2 MG.DL) 1.2
GFR Calculation > 60
Glucose (74-106 MG.DL) 83
Calcium (8.5 ? 10.1 MG/DL) 8.3
Phosphorus (2.5- 4.9 MG/DL) 3.7
Magnesium (1.8-2.4 MG/DL) 2.0

 

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