HISTORY OF PRESENT ILLNESS: patient sustained a gunshot wound to left

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

Objective/outcome

Neuro: The patient is alert and has normal speech, equal pupils of the client and responds to light the sensory and motor skills of the client are intact no facial dropping, but the patient looks distressed Comment by Allison Griffith, MSN, RN: This information is not necessary in the assessment section. You document your abnormal assessment findings of your patient. Also you should prioritize your findings.

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Normal mental status as evidenced by following commands. However, the patient does not look calm

Reduced cardiac output as demonstrated by a reduction in stroke volume Comment by Allison Griffith, MSN, RN: What is your evidence of this diagnosis?

1. At the end of my shift, the elevation of blood pressure of the patient above the limit will reduce

2. At the end of my 8-hour shift, the patient will be calm.

3. The patient will start to engage in activities of the daily living at the end of 8 hours Comment by Allison Griffith, MSN, RN: Comment by Allison Griffith, MSN, RN: The client is n intensive care client with eart failure and she cannot breath onn exertion is this a priorty or realistic for this client?

4. The neurological status of the patient will improve

1. Monitor blood pressure every 1-2 hours

2. Monitor ECG

3. Stay at the bedside of the client to protect her from falling or harm

Regularly monitor the neurological condition of the client to record improvements. (Gulanick &Myers 2014 p.48).

1. After my 8-hour shift, the nursing, the client will not have elevations in heart failure above the normal limits. Goal met. Comment by Allison Griffith, MSN, RN: Is this an expected outcome? Comment by Allison Griffith, MSN, RN: This need clarification alos you ned to have realistic outcomes and interventions. Please apply higher level of critical thinking to your plan of care.

2. The blood pressure will be maintained at acceptable limits. Goal met

3. The client does not experience injuries or fall throughout my shift. Goal met

4. The client will be offered one-one-one sitter by the bedside. Goal met Comment by Allison Griffith, MSN, RN: Why is this necessary?

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

Objective/outcome

Respirations: 23 BPM, SpO2 98% through room air. No friction rub was recorded on auscultation. Adventurous breathing sounds or use of accessory muscles identified.

CV: Temp 98.2 F, PR 10 PR 107 BPM, BP 220/115. S1-S2 heart sounds are irregular. Extra heart sounds heard from the blood vessels when a stethoscope is used. Abnormal sound of blood flow in the blood vessels of the arms and legs, abnormal bilateral pedal pulse + 4, and abnormal bilateral radial pulse + 3.43-gauge IV on Right Internal Jugular Vein. An electrocardiogram shows premature ventricular complex

The oral mucosa of the client is normal. The abdomen is intact-not obese, non-distend able, and no tender.

GU: Concentrated urine with mild pain in urination Comment by Allison Griffith, MSN, RN: Pain upon urination is a problem that you have to address since you documented this in your assessment findings.

Integumentary: Intact skin color that is consistent with the African Americas. No open wounds or rashes, warm but dry skin. Gauge IV of the client is 23.

Reproductive: The client is happily married and has a supportive family

Musculoskeletal: The patient can walk easily, and not stiffness was noted. Bed rest is recommended to reduce fatigue and heart activities.

Offer a calm, restful environment due to her fatigue.

Reduce environmental activity and noise

Reduce the number of visitors as well as the length of stay. Comment by Allison Griffith, MSN, RN: These are not nursing diagnosis. Are these considered nursing interventions?.

Comment by Allison Griffith, MSN, RN: Where is your nursing diagnosis? Also, I don’t know what assessment findings you are addressing because there are so many. Nursing is 24 hours, and it is unrealistic to resolve all of this clients problems in a 8 hour shift. Your careplan is not clear and needs clarification. Please refer to your textbook and review the nursing process to help your understanding. Your plan of care needs to be clear, concise, and correct.

The client does not have complications. However, oral mucous should be observed for possible reactions with medications.

Risk of high blood pressure from a high intake of sodium

1. By the end of my shift, the patient will have reduced stimulation and promote relaxation

2. Reduce physical stress and tension that relates to blood pressure as well as the course of hypertension

3. Minimize adventurous sound in breathing

1. After my 8-hour shift, the temperature of the client will be maintained at an acceptable range

2. The blood pressure will be stabilized

3. Extra sound from the heart sounds will be minimized and finally be eliminated

4. The abnormal sounds of blood flow in the vessels will be controlled

1. The patient should not experience extreme side effects of the medications

2. The oral mucosa should remain intact

1. Help the patient reduce the intake of foods and drinks with a high concentration of sodium.

1. Promote family and patient engagement in care delivery

Utilize the right of the family to get information concerning the health of their loved one. (Gulanick &Myers 2014 p.71).

1. Define and state the desirable limits of blood pressure to the patient and family members

2. Explain hypertension and its impacts on heart blood vessels, brain, and kidneys

3. Help the patients understand the risks factors of heart failure

(Gulanick &Myers 2014 p.39).

1. Nurses should frequently monitor the oral mucosa for the possible side effect of medication.

1. Help patient to identify sources of sodium intakes

2. Encourage patient to reduce or eliminate products like chocolate, tea, and coffee and other caffeine

3. Encourage the patient to engage in mild exercises like walking.

Dietary sodium contributes to fluid retention and elevated BP. (Gulanick &Myers 2014 p.340).

1. At the end of the nursing shift, the patient will maintain a normal respiration

2. Adventures sounds will not be heard in breathing

1. After 8 hours of nursing interventions, the patient was able to verbalize the risk factors of heart failure and hypertension and the treatment regimen.

1. At the end of the 8-hour shift, the oral mucosa of the patient should remain intact.

1. At the end of my shift, I will promote patients' education. Goal met

2. The patient is expected to minimize the risks of heart failure Comment by Allison Griffith, MSN, RN: Patience you are on track, however I need you to apply a higher level of critical thinking. I know you are capable to do so. Please keep pushing and trying, Your grade 72%