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

Credits: Dara Lanman, MSN, RN, CNE

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

The post NURS 1410 Developing Critical/Clinical Thinking by Identifying Relationships in a Patient with Cardiovascular Conditions appeared first on Infinite Essays.



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