NURS 361: Med surg 11: Plan of care

Health History Interview Game

Create a plan of care for this client after watching the video.
NURS 361: Med surg 11: Plan of care

Assessment
The client is a 75-year-old male who presents with a chief complaint of worsening shortness of breath over the past few weeks with mild exertion.
Past medical history is significant for hypertension, hyperlipidemia, and obesity. Surgical history includes a cholecystectomy 10 years ago. Social history reveals he is retired and lives with his wife. He reports being less active over the past year.
On physical exam, he appears comfortable at rest but uses accessory muscles with mild exertion. Lung sounds reveal diffuse crackles bilaterally. Lower extremity edema is 1+. Oxygen saturation is 92% on room air.
Initial labs are notable for elevated BNP and troponin. Chest x-ray shows bilateral interstitial edema. EKG shows sinus rhythm with nonspecific ST-T wave changes. Echocardiogram reveals an ejection fraction of 35% with global hypokinesis.
Diagnosis
Congestive heart failure exacerbation, likely due to systolic dysfunction from hypertensive heart disease
Goals
Improve oxygenation with supplemental oxygen to maintain saturation >92%
Reduce work of breathing and dyspnea with diuretic therapy
Improve cardiac function and symptoms with guideline directed medical therapy including ACE inhibitor, beta blocker, aldosterone antagonist
Patient education on diet, activity, medication compliance, and warning signs of worsening symptoms
Plan
Supplemental oxygen 2L/NC to maintain saturation >92%
Furosemide 40mg IV daily plus lasix 40mg PO daily
Lisinopril 10mg daily, increased as tolerated
Carvedilol 6.25mg BID, increased as tolerated
Spironolactone 25mg daily
Low sodium diet, daily weights, activity as tolerated
Discharge on above medications plus torsemide 20mg daily
Follow up with cardiologist in 1 week and primary care doctor in 2 weeks
Home health referral for medication reconciliation and symptom/weight monitoring
The plan of care addresses the patient’s symptoms, underlying diagnosis, goals of therapy and specific treatments and follow up. Please let me know if you need any clarification or have additional questions!