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J.M. 70 yo male Allergies: Not listed in case study Code status: Not…

- - - - EVALUATION OF INTERVENTIONS:
        Evaluation of intervention #3: Pt remained AAA x 3 today.There was no restlessness or change in mental status.
        Evaluation of intervention #4: The pt understood and stated that he will rest between each activity.
        Evaluation of intervention #5: An EKG was performed and it showed sinus tachycardia with a left bundle branch block.
        
        SMART GOAL:
        Patient will verbalize understanding of all of the medications he is on such as Enalapril, Furosemide, Carvedilol, Digoxin, and Potassium chloride by stating the mechanism of action for each medication as per the nurse-provided medication handout without assistance from the nurse or family during the shift on 4/7/20.
        
        GOAL EVALUATION:
        Goal met. The patient verbalized the medication names and actions as indicated in the previous goal today.
- - - - EVALUATION OF INTERVENTIONS:
        Evaluation of intervention #3: Intake = 1000 mL. Output = 500 mL
        
        SMART GOAL:
        Patient will verbalize understanding of the need to restrict fluid intake to 2 L/day and be able to understand that the feeling of thirst can be decreased with the help of ice chips, gum, hard candy, and ice pops without the assistance of the nursing staff or family members by the end of my shift on 4/7/20.
        
        GOAL EVALUATION:
        Goal met. The patient was able to verbalize understanding of the need to restrict fluid and ways to combat the feeling of thirst as indicated in the previous goal today.
- - - - EVALUATION OF INTERVENTIONS:
        Evaluation of intervention #3: HR was 105 before activity and 130 after activity. The blood pressure was 142/83 before exercise and is now 152/93. There was no shortness of breath before or after activity. These values are made up for the purpose of completing this concept map according to the case study. I realize that I will never make up number or values in real life
        Evaluation of intervention #4: The pt understood and stated that he will progress activities gradually so that he can build up an exercise tolerance.
        
        SMART GOAL:
        The patient will verbalize understanding of the need to consider a cardiac rehabilitation program to improve symptoms of chronic heart failure as per nursing instruction about the cardiac rehab program without the help of the nursing staff or family members by the end of my shift on 4/7/20.
        
        GOAL EVALUATION:
        Goal met. The patient was able to verbalize understanding of the need to consider a cardiac rehabilitation program to reduce symptoms of his chronic heart failure as indicated in the previous goal today.