Include one intervention to address each nursing diagnosis that are still applicable. Impaired gas exchange should still be kept in the plan of care for the resident as they have not meet the expected outcome of oxygen saturation of 95 % in 24 hours. One intervention I would add to this diagnosis would be for the nurse to assist and instruct the patient to deep breathe and perform
Case Study 3 – Congestive Heart Failure Patient Case Question 1. Based on the limited amount of information given above, do you suspect that this patient has developed left-sided CHF, right-sided CHF, or total CHF? right-sided CHF Patient Case Question 2. How did you arrive at your answer to Question 1? right-sided CHF = fluid may back up into your abdomen, legs and feet, causing swelling.
What Is CHF and How Can You Prevent it Nearly 5.1 million people in the United States have been diagnosed with heart failure. Yet so many people don’t have a clue what it is until they have been diagnosed with it. Congestive Heart Failure, or CHF, is a disease that
541). Interventions should be rendered continuously, promptly and appropriately as it can cause life-threatening complications (Holt 2009, p. 26). Apparently, the patient is stable, but continuous assessment and management should be done to avoid recurrences of untoward signs andsymptoms and prevent potential complications. Firstly, continuous assessment and vital signs should be done and these include blood pressure, cardiac rate, respiration, venous distention and skin turgor to assess possible occurrence of fluid overload as a result of rapid administration of large fluid that is often needed to treat the patient with DKA (Smeltzer & Bare 2004 p. 1185). Aside from this, documentation of fluid intake and output should be monitored and documented to assess for circulatory overload and renal function (Holt 2009, p. 61). Significantly, it is integral in the provision of continuous care that nurses reassess the factors that may have contribute or led to DKA, and educate the patient and his family about strategies to prevent its recurrences (Smeltzer & Bare 2004 p. 1186; Lemone, Burke & Bauldoff 2011, p. 551).
The patient will require surgery to repair the hole in the intestines, and subsequently will have a drainage tube, NG tube, and feeding tube. All drains will need to monitored for placement/movement, and drainage. Input and output will be closely monitored and recorded. The patient will remain on NPO, or nothing by mouth, to rest the bowels along with frequent assessments to monitor for infection and bleeding. The nurse will need to monitor for bowel sounds, vital sign changes, temperature changes, pain, abdomen girth, and wound/incision inspections. The following labs will require monitoring: CBC, H&H, albumin, BUN & creatinine, glucose, and ABG’s and lactic acid if sepsis is suspected. Careful and frequent monitoring of labs will alert the nurse if the patient develops sepsis, or hypovolemia due to excessive bleeding (Belinhof, et al., 2012). In addition to vital signs and labs, the nurse will also include patient assessment into consideration before drawing conclusions by means of critical thinking. After the full assessment has been made, the nurse will report any findings to the health care provider that require further investigation or
* Monitor fluid and electrolyte status. Disturbances can have an adverse effect on ICP. Closely monitor IV fluids with the use of an accurate intravenous infusion
Our emotions in many cases affect our perception of events as well as the actions that we take ourselves by permeating our way of thinking, and therefore affecting each thing that we do in that moment. In particular, emotions about the perception of ourselves have been shown to have both the ability to positively and negatively affect our actions and performances in life. This is what can be
This is especially important on those patients admitted with low mortality risk DRGs. This is accomplished by identifying and preventing, potentially avoidable complications and adverse events. For example, patients admitted for syncope and collapse secondary to dehydration will more than likely be placed on IV Fluids. One goal would be to hydrate the patient and reevaluate them throughout their hospitalization for improvement. However, if the patient’s intake and output is not monitored closely, the patient can become volume overloaded and develop symptoms similar to those seen with Right Sided Heart Failure. Once that happens, the patient will require additional medications and additional hospital days because of provider error of not placing an order for the Nurses to monitor his/her volume status.
The right side of heart will increase in size as the muscle builds up and the heart rate will increase due to compensation for the left ventricle. With auscultation, the lungs will sound crackly from the liquid in the alveoli and interstitial space and when assessing respiration rate it is likely to be above thirty breaths per minute (Lewis et al., 2014). The patient may report that they are experiencing dyspnea, nocturia, fatigue, and a productive coughing. They may appear anxious and their skin may look pale (Lewis et al., 2014).
These also includes his daily maintenance It has the correct fluid amount for the patient and providing an appropriate balance of electrolytes.
However, the point is that we feel them physically. Many people feel something and then bury it deep down until they think it’s gone. What you feel does not leave your body or your heart unless you confront it. Emotions are meant to be endured, not ignored. I want to help you confront your emotions, not run around them. Confronting your emotions will allow you to experience happiness, even if something sad or upsetting happens in your day” (Valpone). (elaborate)
Lungs: Upon auscultation, lungs are clear, no dyspnea, wheezing, or crackles. Dyspnea could be a sign of pulmonary embolism, asthma, pneumonia, and pneumothorax. Wheezing could be a sign of anaphylaxis reaction, asthma, bronchitis, emphysema, RSV, COPD, and sleep apnea. Crackles could indicate congestive heart failure, atelectasis, pulmonary fibrosis, interstitial lung disease, and pulmonary edema,
Checketts for adequate hydration by checking many things, but six assessments that are important are: (1) amount of urinary output or yellow urine, (2) normal blood pressure, (3) elastic skin turgor with no tenting (Kalia, 2008), (4) basic metabolic panel (BMP) to assess BUN, creatine, and electrolytes including sodium, potassium, chloride, and bicarbonate (Dehydration, 2016), (5) her level of consciousness (LOC) including confusion and lethargy, and lastly (6) seizures. Other assessments include checking if capillary refill is less than three seconds and if pulse and respirations are normal. I’m also checking to make sure mucus membranes are moist (Kalia, 2008) and if her eyes normal and not sunken in. I’d perform a urinalysis, a CBC to check hematocrit, and finally a blood/urine osmolality (Dehydration,
Signs and Symptoms Sudden pulmonary edema signs and symptoms of can be detected as dyspnea that get worse when lying down, anxiety, pink, frothy sputum produced when coughing that may be tinged with blood, chest pain if pulmonary edema is caused by heart disease, palpitations, pale skin and mucous membranes, and cold clammy skin. There may be a feeling of drowning due to the excessive fluid. Seek immediate medical attention is required if experiencing these signs and symptoms as this could be life threatening (Williams & Hopper, 2015, p. 525).
Evaluation Other desired outcomes are that ECG results shows the client has a normal sinus rhythm and troponin lab result is less than