Reference no: EM133568983
Situation - Mr. Greg Walston is a 70-year-old client admitted to your med-surg floor with the following stating that he has had increasing SOB over the last 3 days and now feels as if he cannot catch his breath at all. The client states he has had a 'fluid problem on and off for the last five years.
Background - Mr. Walston lives with his wife in the family home they have lived in for 40 years. His daughter's house is nearby, and she is very helpful in taking him and his wife to appointments. However, she has 3 children at school that keep her very busy. They remain very sociable attending the local Bocci ball matches and participate in couples bowling.
Past Medical History includes AF, Hypercholesterolemia, CABG's 10 years ago, ex-smoker, positive coronary artery disease family history in one brother and father. Medications include the following: Furosemide 40 mg once daily, however his prescription ran out last week and he has not gotten it refilled; Lanoxin 0.125 mg daily; ASA 325 mg once daily; warfarin 5 mg every evening; and lisinopril 10 mg daily.
Assessment - His height is 165 cm and weight is 75 kg. Next of kin include his wife Annabele and daughter Ambry. BP 90/50 (65), his pulse is irregular, and rate is 80 bpm, SaO2 93% on room air, Temp 36.9°C (98.3°F), RR - 22 bpm, Crackles noted in the lungs about midway up. Abdomen is soft, round, and nondistended. There is no peripheral edema noted. His heart monitor shows AF.
Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?
What do you think are the primary alterations in health with this patient (diagnosis)?
What is the pathophysiology related to the patient's problems?
What are the risk factors for this patient, and do they contribute to the current primary problem?
What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.)?What signs and symptoms are commonly seen with this diagnosis?
What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)
What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)
What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.)?Which intervention would be best for this patient?
What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)?What changes to the patient's condition would you expect to see happen or have happened?
What interprofessional care would be involved in the care of the patient? (Other disciplines - RT, ECG, social worker, etc.)
What patient education would be important for this patient?
Are there any specific safety considerations that should be included in your care?
What are the manifestations of left heart failure?
What is AF that is included in his past medical history?
What ECG changes may be seen?
What are the normal waves on an ECG?
Could his cardiac enzymes be affected by what is going on?
Why would Mr. Walston be on warfarin?
What lab work would be done to ensure that his dose of warfarin is adequate?
What is the worst possible/most likely complication(s) to anticipate based on the primary problem (to prevent death)?
What nursing assessments/nursing interventions will identify this complication EARLY if it develops?