1. Introduction: In this case study, there is a patient named Mr. Wilson who is a 70 years old man. He stated that he had difficulty in breathing and caught a ‘flu’ a week ago. Currently, he has been observed pitting oedema on his lower legs. In addition, the patient had history of heart attacks, which has been diagnosed with congestive heart failure. The case study will provide a complete care plan for the patient. Its aim is to provide a better quality of care for the patient as well as promoting holistic treatment of the patient. The report will firstly assess the patient’s condition by two nursing assessment tools while offering rationale for choosing these assessment tools. The client’s health problems will then be identified and …show more content…
In addition, the client has already been observed oedema in lower legs. Therefore, fluid balance chart, which can record intake and output of fluid, can help to integrate patient’s health status. 3. Client Health Problems: This section is to identify three client health problems the patient has and sort by prioritization. 3.1 Impaired gas exchange. The most serious health problem that the client has is impaired gas exchange. According to Sue Galanes (2007), impaired gas exchange is result from the balance between ventilation and perfusion is offset by a certain condition which affects the efficiency of the gas exchange. On account of client has congestive heart failure that can contribute to dyspnea, which means the efficiency of gas exchange is decreased. One of the significant defining characteristics of impaired gas exchange is dyspnea (Sabtu, 03 Agustus 2013). In addition, it was hard for the patient to talk in long sentence due to difficulty in breathing. Hence, impaired gas exchange is one of the health problems that the client suffered from. In regards of O2 is the basic element that all of cells and organs need, it can be considered as a fuel of human body. Therefore, impaired gas exchange is the most severe health problem the patient has currently. 3.2 Excess Fluid Volume. The second health problem that the client has is excess fluid volume. Fluid volume excess occurs from an increase in total body sodium content and an increase in total body water
In this Assessment nursing course, one of the major things that is taught is the most important part of giving proper care to a patient. Correct patient assessment is needed before any nursing care plan or treatment can be implemented. This post-review of a person’s assessment will demonstrate the proper way to go about assessing a person’s health.
A low partial pressure of oxygen (PaO2) suggests that a person is not getting enough oxygen; Metabolic acidosis->Kidney failure, shock, diabetic ketoacidosis
After reading your post i agree with your response of not choosing Risk for Electrolyte Imbalance. Deficient Fluid Volume was more appropriate since the definition explains that there is decreased intravascular, interstitial, and/or intracellular fluid (Ladwig, Ackley, & Makic Flynn, 2014). This refers to dehydration, water loss alone without change in sodium which is an electrolyte. The symptoms, such as dry mucous membranes, thirst and dizziness that the patient in question presented with in the Emergency Room were more specific to fluid output exceeding the fluid intake.
First the client will weigh himself daily, so that fluctuation in the amount of fluid can be detected quickly. Any major shifts in weight should be reported to the physician and adjustments to the medical regimen can be addressed. Since rapid heart rate is sign of an acute exacerbation, the client should also monitor his blood pressure and heart rate on a daily basis. He should be encouraged to consume a balanced diet that is low in sodium. Adhering to these dietary restrictions will help control his weight and reduce the amount of fluid that may be retained due to sodium
Congestive Heart Failure is when the heart's pumping power is weaker than normal. It does not mean the heart has stopped working. The blood moves through the heart and body at a slower rate, and pressure in the heart increases. This means; the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart respond by stretching to hold more blood to pump through the body or by becoming more stiff and thickened. This only keeps the blood moving for a short while. The heart muscle walls weaken and are unable to pump as strongly. This makes the kidneys respond by causing the body to retain fluid and sodium. When the body builds up with fluids, it becomes congested. Many conditions can cause heart
The following paper will be on the health status and nursing care for patient J.S. Throughout the paper, the reader will be presented with patient information such as: patient history of present illness, pathophysiology of illness, physical nursing assessment, functional health pattern assessment as discussed with patient, laboratory data, applicable nursing diagnoses, and a care plan for two diagnoses. In conclusion will be a brief summary and evaluation of what the author learned from this experience.
During the hemodialysis treatment, the patient asked few questions about the reason for severe shortness of breath. The patient admitted of the increased fluid intake the day after dialysis, in which the patient considered a poor judgement on his part knowing that it is imperative to follow the limitation on fluid intake. There was a window of opportunity to add some nursing education during the treatment. The patient was very receptive. The patient started feeling better after an hour of dialysis treatment, but continuously experiences labored breathing.
The status of the fluid is evaluated through auscultation of breath sounds for crackles, the sounds of the heart for presence of S, daily weight trends and presence of peripheral edema. The presence of pulmonary crackles or the S heart sound confirms there is volume overload in the heart. After discovering overloading in the heart, it is important to take the necessary treatment measures to maintain fluid
In addition, Reginald is more at risk becoming dehydrated as it is common among the elderly, this is because osmoreceptor sensitivity declines with age (Martini, Nath & Bartholomew 2015, p.928). Due to this risk the nurse caring for Reginald should encourage him to increase his intake of fluid by oral rehydration (Gastroenteritis 2015). If Reginald becomes severely dehydrated this can be managed through intravenous fluids of 0.9% sodium chloride (Metheny 2011, p.345). In addition, the nurse should be recording the input and output of Reginald’s fluid through a fluid balance chart as this will indicate if there are any complications (Long & Scott 2015, p.226). This is because dehydration can lead to severe health problems as water comprises approximately 55% in elderly and is essential for cellular homeostasis and life (Popkin, D’Anci & Rosenberg 2011). Furthermore, “dehydration of just 2% loss of body weight can result in significantly impaired physiological responses and performance” (Water 2014). Dehydration has severe effects which can increase the likelihood of Reginald having further health problems, including “thromboembolic complications, urinary tract infections, pulmonary infections, kidney stones, hyperthermia, constipation and orthostatic
If M.G. is currently following her fluid and salt restriction strictly but is still exhibiting the symptoms of fluid
This assignment will present a nursing care study of a patient on a cardiac ward. The patient will be referred to as Ann to maintain confidentiality (NMC, 2008). Ann’s consent was gained prior to starting this care study. The care study will be developed using the Nursing process and the Roper, Logan and Tierney model. These will both be outlined. The assignment will focus on the assessment process and one problem identified during the assessment and the nursing care which followed this.
The purpose of this assignment is to illustrate the ability in a nursing context, to take information given on an assigned Case study scenario and carry out a complete documentation of a care plan for the patient and her specific problems that are present at the given time.. For the plan of care, I will look more in-depth at the scenario and case study provided for Mrs Greta Balodis, focusing on Day One post op care as requested for the documentation provided by the course co-ordinator. Assessing relevant care of Greta, with a view to the information from the case study. Using a full and complete care plan, the information will present in more detail two long term and two short-term key goals and the rationale of the
Your post is very true because we should give special attention to the alcohol withdrawal presented by the patient and we must assess the same and take the necessary measures. “Because all older patients are different and unique in their mental health needs, the nurse should choose the most appropriate nursing outcomes to establish the effectiveness of the nursing care plan” (Tabloski, 2014, p.185). I agree with you that the level of anxiety the patient is presenting will be a precipitating factor for other risks such as suicide, social isolation and major mental complications. The multidisciplinary team is very important to be incorporated into the patient's treatment and together achieve stabilize them for when they are ready and well to
It was during my first week clinical placement in the ward when I came across with the Waterlow risk assessment tool. My mentor made sure that I got all the risk assessment tools commonly used in the ward as these will play a key part in my duty as a qualified staff nurse. True enough, this risk assessment tool became visible in every patient’s charts and serial risk assessment was done on a weekly basis.
There are five nursing problems that may arise as a result of the patient’s primary diagnosis. First problem is she has poorly managed of hypercholesterolaemia, this is a risk factor of stroke. Second problem is she has erratic blood glucose level (BGL), she has type 2 diabetes, and therefore her BGL needs to be well managed. Third problem is she does not believe she is unwell enough to attend to the local indigenous health care services, she needs to attend to the health care services to maintain her health. Fourth problem is Mary’s blood pressure is remained elevated at 140/97. She has hypertension, so she needs a better management of her blood pressure. Fifth problem is Mary has hearing deficit. She may difficult