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91 yo Female DNAR/DNI NKDA BMI:16.8 (Interventions: (Assess VS, HR, RR…
91 yo
Female
DNAR/DNI
NKDA
BMI:16.8
MDX:
Atrial fibrillation with RVR
Acute systolic CHF
PMH:
CVA, HTN, Hyperlipidemia, digenerative joint disease
Labs:
BNP 923 (H)
Imaging
EKG- Atrial fibrillation with RVR with premature
ventricular conduction complexes. Low voltage QRS. Septal infarct
Chest xray- mild vascular congestion
Possible NDX:
Excess fluid volume
Decreased cardiac output r/t cardiac dysfunction
Risk for injury
Activity intolerance r/t decreased cardiac output 2*abnormal heart rate and rhythm
Risk for ineffective cerebral tissue perfusion
Impaired gas exchange r/t excess fluid volume 2* CHF
Risk for shock r/t decreased contractility of heart and increased afterload
Interventions:
Assess VS, HR, RR, BP, temp Q4h PRN
Assess I/O
Daily weight
Auscultate heart tones, assess HR, rhythm, pulses
Assess for edema
Auscultate lung sounds Q4 hr and PRN
Assess LOC and mentation
Tele monitoring
Heart healthy diet
Safe environment, call light, bed low and lock. Frequent rounding
Meds:
Aspirin
Atorvastatin
Clopidogrel
Diltiazem
Carvedilol
Furosemide