Patient: VT

Primary Diagnosis: Heart Failure

Secondary Diagnosis: Chronic Kidney Disease

Third Diagnosis: Type 2 Diabetes

Pathophysiology: This is when the body cannot produce enough insulin or the body becomes insulin resistant. The cells in the body fail to respond to insulin even when the levels are high (Garcia et al., 2020)

Pathophysiology: Heart Failure occurs when blood doesn't pump as well as it should. The heart becomes weak and lead to narrowed arteries. Fluid can also back up into the lungs. (Mayo Clinic, 2023)

Risk Factors: (CDC, 2023)

Risk Factors: (CDC, 2023)

Risk Factors: (CDC, 2023)

Assessment

Musculoskeletal: Resident gets up with staff assistant in the AM. Resident self ambulates to meals with a walker. Resident is able to dress with assistance from the CNA.

Integumentary: Residents skin is warm to touch. Skin is dry. No rash on skin. +2 Edema. Resident wears compression stockings.

Neuro/Psych: Patient is alert and oriented to person, place, and time. Patient is able to respond to questions towards staff. Patient is pleasant and cooperative. Patient is able to take medications. Patient is able to report about hallucinations.

Respiratory/Pulmonary: Respiratory excursion is clear. Respiratoy effort is normal and unlabored. Symmetrical expansion and retraction. Resident has no oxygen. Oxygen was 96.

Cardiac: Regular rhythm. Regular rate. Heart is S1 and S2.

GI: Bowel sounds active. Soft, nontender, passing flatus. Nondistended.

GU: Resident uses a urinal at night. Resident is contient. Resident is able to toilet himself. Urine is clear, yellow, no signs of a UTI. Resident reports no pain with urinating. Resident does dribble occasionally throughout the day. Pullups are changed throughout the day.

Subjective: Resident came to the nursing home placed by the family. Resident has lost most of ADL's, but is able to complete some tasks. Resident has heart failure which contributes to the residents loss of ADLS. Resident also is 86 years old.

Diagnostic Tests

**Diabetes

**Unhealthy diet

**Enlarged prostate

**Hypertension

**45 years or older

**Family history of Diabetes Mellitus

**Physically inactive

Are overweight

**Unhealthy Diet

**Diabetes

**Hypertension

Excessive Alcohol Intake

Valvular Heart Disease

**CAD

Nursing Problems

Problem 1

Problem 2

Problem 3

Problem 4

Risk for Decreased Cardiac Output (priority 1)

Risk for Electrolyte Imbalance (priority 2)

Risk for Ineffective Breathing Pattern (priority 3)

Risk for Unstable Blood Glucose Level (priority 4)

Resident Focused Outcome

Resident Focused Outcome

Resident Focused Outcome

Resident Focused Outcome

Resident will demonstrate knowledge of appropriate diet and carbohydrate intake (Ackley et al., 2008)

Resident will demonstrate the ability to perform pursed-lip breathing and controlled breathing to help manage respiratory status. (Ackley et al., 2008)

Resident will maintain normal serum potassium, sodium, calcium, and phosphorus at the end of the shift. .(Ackley et al., 2008)

Resident will remain free of side effects from medications to have adequate cardiac output at the end of the shift.(Ackley et al., 2008)

Interventions (Ackley et al., 2008)

Interventions (Ackley et al., 2008)

Interventions (Ackley et al., 2008)

Interventions (Ackley et al., 2008)

Medications


Potassium Chloride ER Oral Tablet Extended release 20 MEQ
Give 2 tablets by mouth one time a day for low K+.


NovoLog Injection Solution 100 UNIT/ML (Insulin Aspart)
Inject as per sliding scale: if 60-150=0


Zaroxolyn (Metolazone) Oral tablet 2.5 mg
Give 1 tablet by mouth in the morning every Monday, Wednesday,


(Cleocin) Clindamycin HCI oral capsule 150 MG (Clindamycin HCI)
Give 4 capsules by mouth one time only for per med.


Fingerstick blood sugar d/t running low.
One time a day for DM.


Blood sugar checks QID before meals and at bedtime related to TYPE 2 DIABETES



Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Glargine)
Inject 60 unit subcutaneously every morning and at bedtime.


Bethamethasone Dipropionare External cream 0.05%


Furosemide (Laxis) Oral 80 MG: Give 1 tablet by mouth two times a day related to heart failure


Milk of Magnesia 15 ML: give 30 ml by mouth every 24 hours as needed for constipation.


Uroxatral (Alfuzosin) Tablet extended Release 24 hour 10 MG


Levothyroxine (Synthroid): give 1 tablet Sodium tablet 75 MCG by mouth one time a day for hypothyroidism.


Allopurinol (Alporim) Tablet 300 MG. give one table by mouth in the morning for gout.


Aspirin (Ecotrun): 81 MG: Give 1 tablet by mouth in the morning.


Metoprolol Succinate (Lopressor): 25 MG: give 1 tablet by mouth every morning and at bedtime.


Atorvastatin (Lipitor) Calcium tablet 40 MG. Give 1 tablet in the morning for cholesterol.


Senna Tablet (Sexokot): 8.6 MG. Give one table by mouth one time a day for constipation.


Vitamin D3: table 5000. Give 1 tablet by mouth in the morning every Monday, Wednesday, and Friday.


Glucose Gel 40%: give 37.5 Gram by mouth as needed for DM protocol!

**Hypertension

**High cholesterol

**Heart Disease

**Kidney Disease

Pathophysioogy: Chronic Kidney Disease is a gradual loss of kidney function. The kidneys need to remove wastes and excess fluids from your blood, when then is removed from the urine. The kidneys need to get rid of the waste because the water can build up and can be very dangerous for the body. (Mayo Clinic, 2021)

Kidney infection

Kidney stones

BMP

K: 2.9

Na:137

Chloride: 92

Ca: 10.1

Glucose: 64

CO2: 3

Anion Gap: 12

BUN: 112

Cr: 2.4

GFR: 26

Diagnostic Tests that I would like: Echocardiogram, Stool sample, Urine sample, bladder scan, vitamin D, uric acid, A1C.

CPAP: Resident has a CPAP for help breathing and wears it at night.

Resident has received vaccinations such as COVID 19, and the flu shot.

Nurse will recognize signs of decreased cardiac output such as looking for SOB, fatigue, edema, coughing, clammy skin. (Ackley et al., 2008)

Nurse will monitor for orthostatic hypotension and daily weights, and intake and output. (Ackley et al., 2008)

Nurse will monitor the pulse oximetry and administer oxygen as needed per the health care providers order. (Ackley et al., 2008)

Nurse will monitor urine output to ensure patient is not having any fluid retention. (Nurse Labs, 2023)

Nurse will Identify the resident at risk or the cause of the hyperkalemia such as excessive intake of potassium or decreased excretion. (Nurse Labs, 2023)

Nurse will monitor for signs of metabolic alkalosis such as tachycardia, dysrhythmias, hypoventilation, tetany, and changes in mentation. (Nurse Labs, 2023)

Nurse will monitor respiratory rate, depth, and respirations throughout the day (Ackley et al., 2008)

Nurse will note the pattern of respirations such as if the resident become short of breathe, the nurse can ask the resident if they are short of breathe and complete a tool called the Respiratory Distress Observation Scale (RDOS) (Ackley et al., 2008)

Nurse will auscultate breathe sounds, and then note decreased or absent sounds, crackles, or wheezes. (Ackley et al., 2008)

Nurse will obtain blood glucose before meals and snacks. (Ackley et al., 2008)

Nurse will evaluate A1C levels for glucose control over previous 2 to 3 months. (Ackley et al., 2008)

Nurse will evaluate residents medication regimen for medications that can alter blood glucose (Ackley et al., 2008)

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