Nursing Care Plan Assignment
Directions: Read the following case scenario and complete the nursing process table on the next page.
Anna Gilford, a 69-year-old female, presents to the ED with pallor, dyspnea, and distended neck veins. She denies chest pain but admits to chest “pressure.” Her husband states she has been short of breath for 3 days, with increasing difficulty sleeping, resulting in her spending the previous night in a recliner chair. He also notes that swelling of her feet is worse this morning and that he could not put her slippers on.
Mrs. Gilford reports her height is 5’1” and weight 162 lb. In the ED, her current weight is 175 pounds, an increase of 13 pounds above her stated weight. Mr. Gilford indicates his wife has not been following any specific dietary plan and does not monitor her blood pressure at home.
She has a history of hypertension and coronary artery disease. Medications include Benicar HCT 40/35 daily, Toprol XL 100 mg/d, Lasix 40mg/d, and a potassium supplement; her husband states she hasn’t taken the potassium this week as they haven’t gotten it refilled yet.
Vital signs are B/P 198/102; pulse 120, thread, and slightly irregular; respirations 34; pulse oximetry 79% on room air. Auscultation of the lungs reveals crackles throughout both lower lobes, and a moist-sounding cough which is nonproductive. Mrs. Gilford is placed on oxygen at 4 L/m by nasal canula.
Following a chest x-ray, which shows pulmonary congestion and a moderately enlarged heart, Mrs. Gilford is admitted to the telemetry floor. You receive these STAT laboratory results—BNP level is 1046, and potassium is 2.8. An ECG report is pending.
Create a plan of care addressing her immediate needs using the nursing process (on next page). Remember, your care plan needs to flow, if the nursing problem is cardiac related, the patient goal needs to reflect the cardiac status, the interventions need to help the cardiac problem, and when you evaluate, you evaluate if the patient goal was met, partially met, or not met with supporting cardiac data (you will need to make up your evaluation with data to support. Think about the priority problems!
Include all pertinent subjective and objective data
Priority Nursing Diagnoses
(include all 3 parts of diagnosis if an actual problem)
List one goal/outcome for each nursing diagnosis
(Begin statement with “Patient will”)
How will you implement your plan?
This is what you do.
2 interventions for each diagnosis
How will you evaluate your patient goal?
Goal partially met?
Goal not met?