good afternoon i need a nurse care plan done with the information below , with APA style and 10 references no more than 5 years old
Mr. Kaplan is a 78-year-old jewish white male, he is a retiree and was admitted to the hospital accompanied by his grandson. He is 100kg at a height of 180cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, the patient complained of shortness of breath for 4 weeks which was worsening on the day of admission and worsening cough. Besides, he also experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea, and leg swelling up to his thigh. Mr. Perez was admitted to the hospital for the same problem 4 months ago.
Mr. Kaplan was diagnosed with heart failure on his last admission and he had also been diagnosed with hypertension for 20 years. Before being admitted to the hospital, the patient was taking Lasix 40mg, Eliquis 5 mg, metoprolol 50 mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. The patient is not allergic to any medication and he does not take any traditional medicines at home. His family history revealed that his father had died of ischemic heart disease 4 years ago while his brother has hypertension. As for his social history, he smoked 2-3 cigarettes a day for 35 years and the calculated smoking pack-years was 5 pack years. Besides, Mr. Kaplan also drinks occasionally.
On examination, Mr. Kaplan was found to be alert and conscious but he was having pedal edema up to his knee. Besides, the patient was noted with bibasal crepitations with no rhonchi. His body temperature was normal. However, his blood pressure was found to be elevated upon admission with a record of 179/100 mmHg with an irregular pulse rate at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while a chest X-ray was conducted and revealed that the patient had cardiomegaly. Lab investigations such as full blood count, liver function test, urea, electrolyte test, and cardiac enzyme were done upon admission. His creatinine concentration was found to be 143mol/L. Therefore, the calculated creatinine clearance was 68.8ml/min. Besides, there was also blood found in the urine and the echocardiography showed that the patient has sinus tachycardia and EF 45%. In addition, an ECG test was performed on day 1 and the result indicated that there was a T-wave inversion. The patients INR was 1.04 which was lower than normal while APTT was found to be slightly higher (59.4 seconds). Mr. Kaplans random blood glucose was found to be normal during his hospitalization.
Mr. Kaplan was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient also suffered from hypertension. The management plan included intravenous furosemide 40mg twice daily, Eliquis 5 mg daily, simvastatin 40 mg once at night and ramipril 2.5mg once a day. Besides, the patient was asked to restrict his fluid intake to 500ml per day and oxygen therapy was given to the patient at high flow at 40L/40% using a face mask when the patient was experiencing shortness of breath.
As for his clinical progression, on day 1, the patient complained of shortness of breath, leg swelling, and orthopnea. An echocardiogram showed that he had cardiomegaly. Treatment of CCF was given. Throughout the stay in the hospital, Mr. Kaplan had responded well to the heart failure therapy as there was no more complaint of chest pain or shortness of breath on day 13 and his pedal edema had gradually improved. However, the patient’s blood pressure from day 1 to 9 was fluctuating between the range of 102/67-179/100 mmHg therefore, hypertension treatment was given and blood pressure from day 10 onwards had been seen to fall within the normal range. Furthermore, Mr. Kaplans renal function became progressively worse from 143mol/L on admission to 175mol/L on day 11 and the calculated creatinine clearance on day 11 was 56.2ml/min. Discharge medications same as hospital regimen, O2 2L/m nasal cannula as needed for shortness of breath, follow up with cardiology in 3 weeks and nephrology in 2 weeks. Home with home health services.