NURS 1410 Developing Critical/Clinical Thinking by Identifying Relationships in a Patient with Cardiovascular Conditions
NURS 1410 Developing Critical/Clinical Thinking by Identifying Relationships in a Patient with Cardiovascular Conditions.
NURS 1410 Developing Critical/Clinical Thinking by Identifying Relationships in a Patient with Cardiovascular Conditions
Adapted and used with permission
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Keith Rischer 2011
Christina Wilson
You have been assigned to your patient this am and have been given report. Go to the Patient’s chart and review the most recent information regarding this patient.
Go to patient’s room
Patient’s Chart
Patient’s Chart (click on what you want to review in your patient’s chart.)
Vital Signs
Patient History
Diagnostic Tests
Physician Orders
MAR
Patient History
Patient’s Chart
Main
Mr. Hart, 60 years old, was diagnosed with hypertension and CAD three years ago after experiencing a left anterior MI. Two years ago, his condition worsened and he was diagnosed in early stage heart failure. Today, he comes to the clinic when he becomes concerned that he is becoming SOB at rest, is experiencing episodes of chest tightness, has developed a persistent cough, and is increasingly fatigued with occasional dizziness. He reports that he is noticing shortness of breath on exertion and also some chest discomfort when he exerts himself. He has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He complains of difficulty getting his shoes on the last month because of increased swelling around his ankles. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. over the last 7 days. He admits that he sometimes forgets to take his medications every day. The clinic healthcare provider recognizes that Mr. Hart needs acute inpatient care and coordinates a direct admission to the hospital.
Past Medical History: Hypertension, Hyperlipidemia, CAD, MI three years ago with secondary heart failure
4
Diagnostic Tests:
Main
Patient’s Chart
| Lab | Today | Past |
| BNP | 510 | 300 |
| Troponins | Negative | |
| Cholesterol | 210 | 260 |
Chest x-ray: bilateral diffuse infiltrates consistent with pulmonary edema
Echocardiogram:
Current ejection fraction is 39% with the past ejection fraction at 47%
Electrocardiogram:
| Temp | HR | RR | Lung Sounds | BP | O2 Saturation | |
| 0700 | 98.6 F (oral) | 126 – irregular, bounding | 28, regular, labored | Crackles both lower lobes; cough noted | 150/90 | 90% on 3L Oxygen per nasal cannula |
Main
Patient’s Chart
Main
Patient’s Chart
Health Care Provider Prescriptions:
Oxygen at 3 liters/minute per nasal cannula
Place on pulse oximeter
Strict intake and output, daily weights
Apply anti-embolism stockings
Diet: Sodium-restricted, potassium-modified, low-fat, low cholesterol
Fluid restriction to 1800 mL PO daily
Consult with Cardiac Electrophysiology for possible cardioversion
Furosemide 60 mg one time oral dose now (STAT)
Begin TODAY warfarin 3 mg. PO
Continue home meds
| Medication | 0700-1500 | 1500-2300 | 2300-0700 |
| simvastatin | 0900 20 mg po daily | ||
| lisinopril | 0900 10 mg po daily | ||
| acetylsalicylic acid | 1300 81 mg po daily | ||
| eplerenone | HOLD TODAY 25 mg po daily | ||
| furosemide | 0900 60 mg one time oral dose STAT | ||
| warfarin Begin TODAY | 0900 3 mg po | ||
Main
Patient’s Chart
8
Neuro
Click on the buttons below to find out your assessment information.
Cardiac/
Respiratory
GI /
GU
General
Click on the buttons below to find out your assessment information.
Anxious; Alert & Oriented
Client states that he feels light-headed and a little dizzy.
Cardiac/
Respiratory
GI /
GU
General
Click on the buttons below to find out your assessment information.
Cardiac – Skin pale, cool to the touch, Pulse bounding and noted to be irregular, 2-3+ pitting edema lower extremities. No JVD noted.
Resp – coarse crackles scattered throughout both lung fields. Labored respiratory effort. Patient sitting upright. Coughing noted. Client states that he feels short of breath.
Neuro
GI /
GU
General
Click on the buttons below to find out your assessment information.
GI – Active bowel sounds in all 4 quadrants. Abdomen soft/non-tender. No appetite. Reports that he had a bowel movement yesterday.
GU – Voiding without difficulty, urine clear/yellow. Reports getting up at night to urinate.
Neuro
Cardiac/
Respiratory
General
Click on the buttons below to find out your assessment information.
Other – Denies pain but expresses that his chest feels “tight”. Slight headache. Skin integrity intact. Appears anxious, restless, and reports dizziness.
First Quetion
Patient’s Chart
Main
Cardiac/
Respiratory
Neuro
GI /
GU
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