Nursing

School of Nursing

Nursing 210

Intermediate Medical-Surgical Nursing

Major Clinical Plan of Care

Student Name_____Oluwatosin Elisha________________________ Date____________

Patients initials T.L Race: _______African American_____________________ Age: 59

DOB: Gender: male

Source of Information: __________Nurse_____________________________

Marital Status: N/A

Primary Medical Diagnosis_____Pulmonary Hypertension due to left heart disease___________________________________________________

Secondary Medical Diagnosis: OSA(obstructive sleep apnea), HTN (hypertension), CAD (coronary artery disease) ____________

Vital signs: T 37.4 P R 22 B/P 109/53 SP02 89

Pain Score (1-10) N/A Location ________________________________________

Allergies: None Diet:___________None____________________

Chief Complaint (CC) or Reason for Seeking Emergency Care patient complained of shortness of breath

History of Present Illness or Problem (HPI): patient is a 59-year-old man with 3 vessel CAD, HfpEF (55%), OSA. Who was brought to the ED from cardiology clinic for acute hypoxic respiratory failure exacerbation. Verbalize worsening shortness of breath and that he can only walk from one end of the house to another before becoming short of breath. Previously was able to walk few blocks, also worsening chest pain that occurs with exertion and is relieved with rest with his last episode occurring two days prior to his admission. Denies chest pain currently or shortness of breath at rest. Denies fever, chills, cough, nausea, vomiting confirm compliance with all his medications and does not use a CPAP machine.

Past Medical History (PMH)

Review of Systems (ROS)

General: no nasal congestion, No sore throat, no double vision, no visual disturbance, no nasal congestion, no sore throat, shortness of breath no cough

Cardiovascular; Normal heart rate , regular rhythm, no murmur.

Musculoskeletal; significant pitting edema above the knees, adequate peripheral radial pulses,

Integumentary; warm,dry. Peripheral catheter line in place

Skin:

clear

Musculoskeletal:

No back pain, No joint pain

Head and Neck:

Endocrine:

No excessive thirst, No polyuria

Females: Menses, Pregnancies, Breast

Males: Prostate:

Chest and Lungs:

Chest pain

Heart and blood vessels:

Hematologic:

Lymph Nodes:

Gastrointestinal: soft, non tender.

Genitourinary:

No dysuria, No hematuria

Neurological: No numbness, No tingling

Psychiatric/Mental Health:

none

Physcial Exam

General:

Alert oriented no acute distress

HEENT:

Neck:

Chest and Lungs: chest pain

Cardiovascular chest pain , No palpitation

Abdomen/gastrointestinal: No nausea No vomiting

Genitourinary: No dysuria, No hematuria

Rectal:

Musculoskeletal: No back pain, No joint pain

Lymphnodes

Skin: clear

Neurological:

No numbness, No tingling

Psychiatric/Mental Health:

None

IVF’s

1) IV solution ordered:

Rate ml/hr

Rationale for solution:

2) IV solution ordered:

Rate ml/hr

Rationale for solutions:

Drips

IV drip ordered:

Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.

Show calculations

Rationale for solution:

Show calculations

IV drip ordered:

Rate_____________gtts/min-mcg/kg/min- unit/hr, units/kg/hour.

Show calculations

Rationale for solution:

Show calculations

Rev 10/2021

Medical Diagnosis: Pulmonary hypertention

Pathophysiology of disorder:

References

RESEARCH ARTICLE (Please Attach)

Author(s)-must be written by at least one nurse:

Year (no later than the last 5 years):

Journal Name:

Volume, Issue, and Pages:

Title:

Summary of article in your own words, and how to best incorporate in your plan of care.

______ _____________________________________________________________________________________________________