Sample Interdisciplinary Care Plan

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Interdisciplinary Care Plan
Marcia Garcia Enriquez
Chamberlain College of Nursing
Critical Care Nursing: NR 340
January 2016
Interdisciplinary Care Plan M.S. presented to the Emergency Room on February 2, 2016 with complaints of abdominal pain with chronic shortness of breath. M.S. revealed tachycardia during triage. EKG presented new onset atrial fibrillation, atrial flutter, and labs expressed elevated troponin I levels. M.S. was transferred to the telemetry unit for further treatment. M.S. is an 80 year-old Black American born on August 29, 1936. Upon report on February 3, 2016 M.S. has no known allergies and has elected to be a status full code. Overnight M.S. came out of atrial fibrillation with rapid ventricular …show more content…

is divorced and lives with one of his biological daughters. M.S. has two biological daughters and four stepchildren. M.S. is retired from labored employment. M.S. has no history of elicit drug or alcohol abuse. M.S. weighs in at 86.5 kg and stands at 180 cm. M.S. has a history of hypertension, hyperlipidemia, and diabetes mellitus. M.S. surgical history includes a tendon repair of the left knee when he was age 78, a bunionectomy of the left knee and bilateral carpel tunnel at age 60.

Review of Systems
Cardiovascular
BP 106/74 Blood pressure may be affected due to Rx
Pulses 2+ WDL
Rhythm Regular/Tachycardia WDL
Apical Rate 106 As a result of disease process
Radial 108 As a result of disease process
Capillary Refill < 3 seconds WDL
Heart Sounds S1 S2 heard. No murmur on auscultation WDL Respiratory
Rate 16 WDL
Rhythm Regular WDL
Effort Symmetrical chest wall expansion, nonlabored. WDL
Pulse Oximetry 100% Room air WDL
Breath Sounds Equal bilaterally, diminished. WDL
Cough None, no secretions present WDL
Mucous Membranes Pink, moist WDL

Gastrointestinal
Abdominal Contour Rounded, nontender, nondistended …show more content…

Bleeding, HIT, anemia Make sure patient is placed on high bleed risk. Advise patient to report any signs of unusual bleeding or bruising to HCP immediately. Atrial fibrillation is known to place the patient at high risk for formation of blood clots (Sole, 2013)
Digoxin
Lanoxin 250 mg
1 tab
PO
BID Antiarrythmics
Inotropics Atrial fibrillation and atrial flutter (slows ventricular rate). Increases cardiac output and slowing of the heart rate Arrhythmias, fatigue, bradycardia, anorexia, nausea, vomiting, weakness Monitor ECG throughout IV administration
Withhold if pulse is s diagnostic and laboratory test reference (11th ed.). St. Louis, MO: Elsevier Mosby.
Parwani, A.S., Boldt, L, Huemer, M, et al. (2013). Atrial fibrillation – induced cardiac troponin I release. International Journal of Cardiology. 2013;168(3):2734-7. DOI:10.1016/j.ijcard.2013.03.087.
Sole, M.L., Klein, D.G., & Moseley, M.J. (2013). Introduction to critical care nursing (6th ed). St. Louis, MO: Elsevier.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2013). Davis’s Drug Guide for Nurses. (13th ed). Philadelphia, PA: F.A

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