69-year-old female with a history of coronary

69-year-old female with a history of coronary artery disease, and hypertension presents by DPS ambulance to your emergency department, the morning after her birthday, with progressive shortness of breath. She has noticed shortness of breath at night and has been resting on at least two pillows. Last night she was unable to sleep and had to stay in her recliner chair until she called the paramedics this morning. She denies chest pain now or at any time this week. She admits that she failed to follow her low salt diet and states she may have missed some of her medications this week. Her vital signs are HR 105, BP160/80, RR 32, and O2 saturation of 89% on 100% non-rebreather oxygen mask. Physical exam: Your patient is in moderate respiratory distress, sitting forward, and speaking in only three-word sentences. HEENT: She has no stridor. Jugular venous pressure is elevated to the mandible. Chest: Crackles are heard in all lung fields without wheezing. Cardio: She has normal S1and S2. An S3 is present. There is no murmur. Abdomen: She has no tenderness, no hepato-splenomegaly, and no masses on exam. Extremities: She has two plus pitting edema to the level of the tibial plateau. Neuro: She is awake with no weakness, numbness, speech or vision deficits. Skin: She is pale with central cyanosis, cool to touch, and diaphoretic. Vital Signs Day 1 12nn 4pm 8pm 12mn PR 100 100 95 90 RR 30 31 29 29 BP 160/70 160/70 150/70 150/70 Temperature 38.7 38.5 38 37.5 Day 2 4am 8am 12nn 4pm PR 80 59 85 100 RR 28 28 26 26 BP 150/60 150/60 150/60 150/60 Temperature 37.3 36.9 36.9 36.5 Ultrasound Results are: B-lines in left lung field suggesting interstitial edema PSL, Dilated Left Ventricle with poor contraction and poor mitral valve excursion suggesting diminished Ejection Fraction (EF) CXR Results are: cardiomegaly and effusions Peribronchial cuffing – thickened bronchial walls secondary to edema. Perihilar congestion – large hila with indistinct margins suggest pulmonary vasculature edema. Pleural effusion – meniscus at the angle of the diaphragm. Kerley B lines – Dilated lymphatic channels. Typically, 2 cm in length and horizontal, peripherally located perpendicular to pleura. Other Laboratories CBC to check for anemia Electrolytes: Na, K, Mg for abnormalities due to fluid overload or renal insufficiency Creatinine to check for renal dysfunction Troponin I or T to check for acute ischemic event. ECG : shows underlying cardiac ischemia, dysrhythmias, LVH or heart block. ECG has a high negative predictive value for systolic dysfunction. Meds Given: Nitroglycerin 0.6 mg 1tab sublingual OD Morphine Sulphate 10mg IV PRN Furosemide 10mg IV q 8hrs Digoxin 0.25 mg PO OD. QUESTION: 1. Formulate nursing care plan appropriate to the condition of the patient. NURSING CARE PLAN Nursing Assessment: Subjective data: Objective data: At least 3 Nursing Diagnosis: Nursing Inference: Nursing Goal/Outcome: Nursing Interventions Rationale Nursing Evaluation:

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