Congestive heart failure nurse care plan

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good morning, I need you to make me a congestive heart failure care plan with all the documents that I leave below and to fill out the care plan model with the information that appears in the paragraph and to be guided by the Apa style , I also need 5 references that are from 2015 onwards

Mr. Kaplan is a 78-year-old jewish white male, he is a retiree and was admitted to the hospital accompanied by his grandson. He is 100kg at a height of 180cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, the patient complained of shortness of breath for 4 weeks which was worsening on the day of admission and worsening cough. Besides, he also experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea, and leg swelling up to his thigh. Mr. Perez was admitted to the hospital for the same problem 4 months ago.

Mr. Kaplan was diagnosed with heart failure on his last admission and he had also been diagnosed with hypertension for 20 years. Before being admitted to the hospital, the patient was taking Lasix 40mg, Eliquis 5 mg, metoprolol 50 mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. The patient is not allergic to any medication and he does not take any traditional medicines at home. His family history revealed that his father had died of ischemic heart disease 4 years ago while his brother has hypertension. As for his social history, he smoked 2-3 cigarettes a day for 35 years and the calculated smoking pack-years was 5 pack years. Besides, Mr. Kaplan also drinks occasionally.

On examination, Mr. Kaplan was found to be alert and conscious but he was having pedal edema up to his knee. Besides, the patient was noted with bibasal crepitations with no rhonchi. His body temperature was normal. However, his blood pressure was found to be elevated upon admission with a record of 179/100 mmHg with an irregular pulse rate at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while a chest X-ray was conducted and revealed that the patient had cardiomegaly. Lab investigations such as full blood count, liver function test, urea, electrolyte test, and cardiac enzyme were done upon admission. His creatinine concentration was found to be 143µmol/L. Therefore, the calculated creatinine clearance was 68.8ml/min. Besides, there was also blood found in the urine and the echocardiography showed that the patient has sinus tachycardia and EF 45%. In addition, an ECG test was performed on day 1 and the result indicated that there was a T-wave inversion. The patient’s INR was 1.04 which was lower than normal while APTT was found to be slightly higher (59.4 seconds). Mr. Kaplan’s random blood glucose was found to be normal during his hospitalization.

Mr. Kaplan was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient also suffered from hypertension. The management plan included intravenous furosemide 40mg twice daily, Eliquis 5 mg daily, simvastatin 40 mg once at night and ramipril 2.5mg once a day. Besides, the patient was asked to restrict his fluid intake to 500ml per day and oxygen therapy was given to the patient at high flow at 40L/40% using a face mask when the patient was experiencing shortness of breath.

As for his clinical progression, on day 1, the patient complained of shortness of breath, leg swelling, and orthopnea. An echocardiogram showed that he had cardiomegaly. Treatment of CCF was given. Throughout the stay in the hospital, Mr. Kaplan had responded well to the heart failure therapy as there was no more complaint of chest pain or shortness of breath on day 13 and his pedal edema had gradually improved. However, the patient’s blood pressure from day 1 to 9 was fluctuating between the range of 102/67-179/100 mmHg therefore, hypertension treatment was given and blood pressure from day 10 onwards had been seen to fall within the normal range. Furthermore, Mr. Kaplan’s renal function became progressively worse from 143µmol/L on admission to 175µmol/L on day 11 and the calculated creatinine clearance on day 11 was 56.2ml/min. Discharge medications same as hospital regimen, O2 2L/m nasal cannula as needed for shortness of breath, follow up with cardiology in 3 weeks and nephrology in 2 weeks. Home with home health services.

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STUDENT NAME: DATE:

CLIENT’S INITIALS: CLIENT’S AGE: GENDER: M / F ALLERGIES: Advance Directives: Restrains: Y / N DIET (including tube feeding with rate)

Admitting Medical Diagnosis:

Chief Complaint:

History of Present illness:

Past Medical History:

Cultural and Spiritual Assessment:

Medications taken at home or before transfer: (include dose and frequency)


Summarize Pathophysiology (in our own words, include definition, etiology and physiology)

Definition of Concurrent Diagnoses (all of them)

Correlational of all diagnoses with current condition

Signs and Symptoms: (Indicate which ones your client has)

Diagnostic test for this condition: (Indicate which ones utilized for client)

Treatment (med/surg/pharmacological)

Nursing Interventions and rationale:

Medications administered during client assignment including IVF’s, Rate, and reason for Fluids.


Generic/Trade Name Classification

Major Action

Reason Prescribed to Client

Dose Given/Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication

.

Generic/Trade Name Classification

Major Action

Reason Prescribed to Client

Dose Given/

Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication

Generic/Trade Name Classification

Major Action

Reason Prescribed to Client

Dose Given/

Normal Range

Adverse Effects

Precautions/Contraindications

Nursing Implication


LABORATORY AND DIAGNOSTIC TESTS

Other Pertinent labs

DATE

DIAGNOSTIC STUDY

RESULTS

SIGNIFICANCE TO PATIENT


NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS

SCIENTIFIC PRINCIPLE/ RATIONALE

EVALUATION

MODIFICATION


NURSING DIAGNOSIS R/T AND EVIDENCED BY

Subjective Supportive Data

Objective Supportive Data

NURSING ACTIONS

SCIENTIFIC PRINCIPLE/

RATIONALE

EVALUATION

MODIFICATION

DISCHARGE PLANNING

CLIENT’S NEED FOR DISCHARGE

INTERVENTIONS

RATIONALE

7th Edition
Reference Guide for Journal Articles,
Books, and Edited Book Chapters

Journal
Article

Author, A. A., & Author, B. B. (Year). Title of the article.

Name of the Periodical, volume(issue), #–#. https://doi.org/xxxx

Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.

Place the year
in parentheses.
End with a period.

Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title. Also
capitalize proper nouns. Do not italicize. End with a period.

Capitalize all major words in the
periodical name. Follow with a
comma. Italicize the periodical
name (but not the comma after).

Italicize the volume number. Do not
put a space between the volume
number and the parentheses
around the issue number.

Do not italicize the issue number or
parentheses. Follow the parentheses with
a comma. No issue number? That’s okay.
Follow the volume number with a comma.

Include the article page
range. Use an en dash; do
not put spaces around the
en dash. End with a period.

Does the article have a
DOI? Include a DOI for all
works that have one. Do not
put a period after the DOI.

Book
Author, A. A., & Author, B. B. (Copyright Year). Title of the book (7th ed.).

Publisher. DOI or URL

Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.

Place the copyright year
in parentheses. End with
a period.

Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title. Also
capitalize proper nouns. Italicize the title. End with a period.

Include the name of the publisher, followed
by a period. Do not include the publisher
location. Are there multiple publishers?
If so, separate them with a semicolon.

Does the book have a DOI? Include a DOI if available.
Do not include a URL or database information for works from
academic research databases. Include a URL for ebooks from
other websites. Do not put a period after the DOI or URL.

Does the book have an edition or volume number? If so, include
the number in parentheses after the title but before the period. If both,
show edition first and volume second, separated by a comma. Do
not put a period between the title and the parenthetical information.

Chapter in
an Edited Book

Author, A. A., & Author, B. B. (Copyright Year). Title of the book chapter.

In A. A. Editor & B. B. Editor (Eds.), Title of the book (2nd ed., pp. #–#).

Publisher. DOI or URL

Invert names so that the last name comes first,
followed by a comma and the initials. Leave a space
between initials. Retain the order of authors’ names.

Place the copyright year
in parentheses. End with
a period.

Capitalize only the first letter of the first word. For a two-part
title, capitalize the first word of the second part of the title.
Also capitalize proper nouns. Do not italicize. End with a period.

Write the word “In” and the initials
and last name (not inverted) of
each editor. Use “(Ed.)” for one
editor or “(Eds.)” for multiple
editors. End with a comma.

Provide the title of the book in which
the chapter appears. Capitalize only
the first letter of the first word. For a
two-part title, capitalize the first word
of the second part of the title. Also
capitalize proper nouns. Italicize the
book title.

Include the chapter page range. End with a period.
Does the book have an edition or volume
number? If so, include the number in parentheses
before the page range. If both, show edition
first and volume second, separated by a comma,
before the page range. Do not put a period
between the title and the parenthetical information.

Include the name of the publisher followed
by a period. Do not include the publisher
location. If there are multiple publishers,
separate them with a semicolon.

Does the book have a DOI or URL? Include a DOI if available.
Do not include a URL or database information for works from
academic research databases. Include a URL for ebooks from
other websites. Do not put a period after the DOI or URL.

More information on reference variations not shown here (e.g., in-press articles, articles with article numbers, articles without DOIs, books with titled volumes,
audiobooks) can be found in the Publication Manual of the American Psychological Association (7th ed.) and in the Concise Guide to APA Style (7th ed.):

Journal articles and other periodicals Section 10.1
Books and reference works Section 10.2
Edited book chapters and entries in reference works Section 10.3

SOURCE: American Psychological Association. (2020).
Publication manual of the American Psychological
Association (7th ed.). https://doi.org/10.1037/0000165-000

CREDIT: MELANIE R. FOWLER, FLORIDA SOUTHERN COLLEGE

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