Looking for input for cardiac column of care plan

chevyv, BSN, RN · Feb 15, 2009

I'm hoping for some help with the cardiovascular part of my care plan. Here is the information that I have for that column:

History of hypertension.

Denies chest pain and shortness of breath (no physical indication).

Nail beds: pink

Lips: pink

Mucous membranes: moist and intact.

No jugular venous distension.

CRT less than 3 sec all extremities.

No edema in upper extremities or in lower left extremity. Generalized edema in lower right extremity r/t right hip replacement.

Blood pressure:

2/11 118/68

2/12 108/58 in left arm

Normal range both days.

Labs:

Potassium 2/11 3.4

2/12 3.4

Normal range: 3.5-5.1

Magnesium 2/11 1.7

2/12 1.6

Normal range: 18.-2.4

Sodium 2/11 133

2/12 131

Normal range: 136-145

Protime 2/11 15.0

2/12 14.1

Range: 9.4-12.2

INR 2/11 1.40

2/12 1.31

Low range 2.0-3.0

High range 3.0-4.0

Digoxin level: 1.2 (in therapeutic range of 0.9-2.0)

2/12

HGB 10.6 (11.5-15.5)

HCT 31.3 (35.0-46.0)

RBC 3.37 (3.70-5.20)

MCV 93

MCH 31

PLT 413

Meds:

Digoxin: 250 mcg daily

Cardizem 30mg (d/c'd 2/12).

Lasix 20 mg bid

Ferrous sulfate 325 mg daily.

Folic acid 1mg daily

Magnesium chloride 1 tab bid

Magnesium sulfate 2g 1 time (given 2/11 and 2/12 IV).

2/11Potassium chloride 20mEq (sustained release) 1 time order PO.

2/11 Potassium chloride Concentrate 20mEq bag IV.

2/12 Potassium chloride concentrate 40mEq bag IV.

Warfarin 2mg daily PO

2/9/2009

EKG- sinus tachycardia with ventricular rate of 113 bpm. Occasional premature ventricular complex noted. QRS duration within normal range. No acute ischemic changes.

TED stockings on at all times (below knee).

There are a few things going on here that have me stumped as far as coming up with a diagnosis. First, potassium and magnesium are low. Pt just can't seem to get and keep these levels up. I need to mention that patient also had a pneumothorax where 550 mls of fluid was removed just a day or 2 before I came on board. That is in the respiratory column of my care plan. Pts heart rate has been in the upper 80's for the time that I've been there.

Lung sounds are diminished in all fields. No sob, CRT less than 3 sec. Skin is warm, pink, and dry. Pt presented to er after a fall with a fx hip. Surgery went well, but now the K and mg just can't get stable.

Should I be looking at a possible decreased cardiac output for a dx?

I know I shouldn't be doing at risk for, because there is obviously more going on than at risk stuff. I just can't seem to see the big picture here. Any help would be appreciated.