SIMCLEX 49443c77 - NURSING.com

EHR for Patient

This is a 68-year-old female admitted with heart failure. Patient was diagnosed with heart failure two years ago after suffering a myocardial infarction with significant damage to her left ventricle.

Day of admission

1000 Admission completed. Awake, alert, and oriented to person, place, and time. Heart rate 96 with S3 sounds noted. Will continue to monitor. Lung sounds with crackles in bilateral bases. Reviewed need for daily weight. Discussed health promotion regarding need for annual influenza vaccination.

1300 Care plan implemented. Patient complains of difficulty breathing when lying flat. Care priorities will focus on decreasing fatigue. Activity to be increased as tolerated. Need for routine exercise discussed. Decrease in peripheral edema will be a priority.

Day 2

0800 Daily weight implemented on admission. No weight gain has been noted. Dietary consult for diet plan to achieve and maintain healthy weight. Inability to ambulate more than 20 feet without significant dyspnea. New medication ordered by provider for uncontrolled hypertension. Oxygen administered per orders to maintain oxygen saturation > 94%. Lung sounds with bilateral lower lobe crackles.

Discharge Note:

Discharge note: Pneumococcal vaccine recommended. Patient able to maintain oxygen saturation > 94% without supplemental oxygen. Need for regular exercise discussed. Activity tolerance has been increased and able to ambulate throughout hallways without any supplemental oxygen or shortness of breath noted. Evaluated by respiratory therapy to determine appropriateness of home oxygen. Systolic blood pressure consistently under 140 after starting new hypertension medication regimen.

This is a 68-year-old female admitted with heart failure. Patient was diagnosed with heart failure two years ago after suffering a myocardial infarction with significant damage to her left ventricle. She has managed her heart failure well over the past two years and has not required previous hospitalization to manage her heart failure. She is slightly overweight with a BMI of 27. She has a history of hypertension and is currently being treated with beta blockers and an ACE inhibitor.

She presented to the emergency department last night after experiencing significant difficulty breathing while sleeping. Her oxygen saturation on arrival to the emergency department was 87% on room air and her blood pressure was 198/102. She was placed on BiPAP for approximately 1 hour. After that time her blood pressure was improved and her oxygen saturation was 94% on 3 liters via nasal canula. She reports a daily weight gain of 1-2 pounds per day over the past week with increasing shortness of breath. She has bilaterally 3+ pitting edema in her lower extremities. She states that for the past two days she has been unable to complete her normal activities of daily living due to severe dyspnea.

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Review the history and physical info. Based on the patient’s history and physical info, identify the documentation that most closely relates to the identified phase of the nursing process by highlighting in row of column 2 in the table below:

Nursing Process:	Nursing Documentation:
Assessment	Admission completed. Awake, alert, and oriented to person, place, and time. Heart rate 96 with S3 sounds noted. Will continue to monitor. Lung sounds with crackles in bilateral bases. Reviewed need for daily weight. Discussed health promotion regarding need for annual influenza vaccination.
Diagnosis	Pulmonary edema Impaired gas exchange Impaired cardiac output Fluid imbalance Anxiety Activity intolerance Hypoxemia
Planning	Care plan implemented. Patient complains of difficulty breathing when lying flat. Care priorities will focus on decreasing fatigue. Activity to be increased as tolerated. Need for routine exercise discussed. Decrease in peripheral edema will be a priority.
Implementation	Daily weight implemented on admission. No weight gain has been noted. Dietary consult for diet plan to achieve and maintain healthy weight. Inability to ambulate more than 20 feet without significant dyspnea. New medication ordered by provider for uncontrolled hypertension. Oxygen administered per orders to maintain oxygen saturation greater than 94 percent. Lung sounds with bilateral lower lobe crackles.
Evaluation	Discharge note: Pneumococcal vaccine recommended. Patient able to maintain oxygen saturation greater than 94 percent without supplemental oxygen. Need for regular exercise discussed. Activity tolerance has been increased and able to ambulation throughout hallways without any supplemental oxygen or shortness of breath noted. Evaluated by respiratory therapy to determine appropriateness of home oxygen. Systolic blood pressure consistently under 140 after starting new hypertension medication regimen.

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