{Author Name [first-name middle-name-initials last-name]}
{Institution Affiliation [name of Author’s institute]}
Care Plan Template
Patient Initials: XYZ Age: 52 Sex: Male
Subjective Data:
HPI: Stent placement with four days hospitalization. The patient was also showing angina symptoms thus admitted to emergency. He was feeling severe chest pain for four hours along with shortness of breath with exertion and diaphoretic. The symptoms existed for four days and on being a severe condition he needed intense care and visited to the hospital.
The symptoms were six months old and after some rest it used to be normal. He received urgent care in emergency through medication to relax the symptom. Following that he was shifted to cardiac section for further procedure of cardiac catheterization.
PMH:
Not received any proper care related to the symptoms in the past
The patient was treated with hypertension and high cholesterol but terminated medication without counseling care provider.
No history of any other significant illnesses, allergies or heart disease except high cholesterol levels.
Hospitalized for a cholecystectomy ten years ago, Post Cholecystectomy, no complications
Initially exhibited baseline EKG thus prescribed blood pressure medication.
ROS is negative
Taking medications prescribed post stent placement by the physician from the coronary care unit
Tenormin XL 50 mg daily
Lipitor 10 mg daily
Glucophage – 500mg BID Baby ASA daily
Patient is taking medicines on time though it was not same earlier
Patient demonstrated no drug allergies
Significant Family History: Positive family history
Social/Personal History:
Patient is a high school graduate and a licensed carpenter by occupation earning $50,000.00 per year, Not a strong financial background
Patient’s wife has uncontrolled type 2 diabetes
Patient is worried about his spouse’s health
Father of three grown-up children who are not living with him now
Patient is not physically active and does not participate in sport activities
Living in a low profile area and does not socialize in community
Diet habits are not satisfactory
Skips breakfasts, and have fast food in lunch
Takes a large meal in the evening after work mostly pasta and meat
Not sufficient consumption of fruits and vegetables with smoking habit
Description of Client’s Support System:
Lives alone with his wife
Has little emotional or social support
Staying in a single bedroom apartment isolated from their community
Now suffering from depressive symptoms including excess of sleep and eating
Patient owns a health insurance that is not sufficient to provide a complete coverage of his prescription and medications so he prefers the clinic linked to his hospital
Behavioral or Nonverbal Messages:
Self-efficient, responsible and caring
Behaviorally strong to combat any illness or problem
Post stent placement procedure he is worried about any incidence of angina pain
Understands the associated risks factors thus frequently visits clinic for consultation
Patient considered himself sufficiently active whole life and his professional activities were sufficient against his exercise requirement
Objective Data:
Vital Signs including BMI:
BMI not mentioned
Associated risk factors include
High blood pressure
Hypercholesterolemia
Android obesity
Type 2 diabetes
Cigarette smoker
Positive family history
Physical Assessment Findings:
Cholesterol – 210 (Very high)
LDL- 200
HDL- 25 (Very less, high risk to heart problems)
Triglycerides – 250 (High)
Fasting blood sugar – 140 (Diabetic)
HgbA1c – 7.5
CXR shows hyperinflation of the lungs that may be due to smoking habit, no infiltrate
EKG - no change from baseline
Little emotional support
Insufficient health insurance coverage
No financial support
The client has an internal locus of control indicating he is aware of the situation and can control it with several external factors including medication, proper care, and counseling with health care providers (Lefcourt, 2013). Client is compliant now that indicates his readiness to learn.
ICD-10 Diagnoses/Client Problems:
According to ICD 10 Data (Icd10data.com, 2016), a cardiac problem due to hypertension comes under diagnosis code I11.0, and the problem of angina pectoris comes under the I20.9 code.
Advanced Practice Nursing Intervention Plan
Coronary artery disease is commonly caused by insufficient oxygen in the myocardial tissue due to scarce blood flow. The expected outcomes of the nursing interventions will be to maintain the appropriate amount of blood flow to that artery which was deprived of oxygen previously.
Nursing interventions
Post stent surgical procedures
References
Lefcourt, H. M. (Ed.). (2013). Research with the locus of control construct: extensions and
limitations (Vol. 3). Elsevier.
Icd10data.com,. (2016). 2016 ICD-10-CM Diagnosis Codes I50.* : Heart failure. Retrieved 18
