Question

Patient is a 76 year old male who was admitted to the hospital for pulmonary embolism, cardiomyopathy, left ventricular thrombus, ischemic cardiomyopathy. No known allergies. He has history of HTN and hyperlipidemia. Over the past 2 months, he was experiencing SOB particularly with exertion. Patient visited primary care provider on the 29th who directed him to ED for further evaluation. In the ER, found to be afebrile, hemodinamically stable, saturating 95% RA. Lab work-up notable for troponin of 61. CTA chest done showed pulmonary emboli of the secondary and tertiary right lower lobe branches, no saddle emboli. Hospitalist team was called for admissions further management.

Now, he has telemetry on reading 61-67 HR. He was complaining of right knee pain and lower back that radiates to his neck. Administered Tylenol for his lower back and neck pain. Neck also has Lidoderm patch. He did not complain shortness of breath or chest pain during my shift. He also complaint of pain when elevating his legs, so his legs were mostly down during my shift. Dr. said he must be experiencing gout due to his medications not because of his diet. He was sitting on the side of the bed most of my shift. He's on a cardiac diet and tolerating well. Recent vital signs were: BP: 120/77 , Pulse: 67 , RR: 16 , Temp: 98.6F , O2 sat: 99%. Upper lobes were clear, crackles to bilateral lower bases. Patient is independent, steady gait, 1+ pitting edema to bilateral lower extremities. Waiting for a life vest. Getting discharge tomorrow.

Medications:

Aspirin 81 mg

Capsaicin cream to right knee

Spinoralactone 25mg

Lasix Injection 4mL IV

Lidoderm patch to neck

Toprol XL tab 50mg

Lisinopril tab 5mg

Colchicine

Coumadin 4mg PO (HOLD because of INR 3.05)

Potassium Chloride 40mEq PO ONCE

Laboratory Tests:

WBC: 9.8 , RBC: 5.04 , Hgb: 14.5 , Hct: 45.7 , Plt: 166 , Na: 139 , Potassium: 3.5 , Chloride: 100 , CO2: 28 , BUN: 13 , Creatinine: 0.97, Calcium: 9.3

Glucose: 111 H , Uric Acid: 11.7 H , Magnesium: 2.2 , Phosphorus: 4.4

EST GFR AfAM: 88 L

EST GFR NonAf: 76 L

PT: 30.6 H

INR: 3.05

APTT: 113 H

Questions:

- What are the nursing diagnosis?

- What are the three top problems for this patient? Include "related to" and "as evidenced by".

- What are the goals presented for priority problems are listed with measurable outcomes?

- What are the interventions (at least one education intervention) Relationships apparent between interventions and each goal/outcome and problem. Be concise and clear, achievable, relates to the stated diagnosis and client outcome.

- Evaluation: States how client outcome was met, what might have helped or hinder attainment of the outcome, analyzes the care given. If needed, revisions in the care plan done; interventions, assessment, state if should have done something differently in retrospect.

Answer 1

Nursing diagnosis	inervention	Goal	Evaluation
Altered comfort related to pain as evidenced by patient's statement" pain on elevating the leg, back pain, neck pain"	Assess the intensity of pain. Administer analgesics. Provide comfortable position. Teach nonpharmocological methods to relieve pain	Reduce the pain intensity	Patient seems comfortable and given leesr number in pain scale Can be evaluated by asking him or from facial expression by using pain scale.
Ineffective tissue perfusion and risk for deep vein thrombosis related to decreased peripheral circulation as evidenced by edema and pain	Monitor and measure edema Encourage to move the legs frequently Administer medication( lasix, spironolactone)	Increase the perfusion	Pateint experience an increased perfusion This can be evaluated by bilateral lower limb doppler.
Risk for bleeding or injury related to anticoagulation therapy as evidenced by lab investigation( INR 3.05 with Warfarin)	Assess skin and mucous for bruices, erythema. Adjust or stop the dose of warfarin according to coagulation result Educate the patient to do laborotary investigations regularly Educate the patient to avoid forceful nose blowing,straining for bowel movement, use of suppositorie etc	Patient is free from bleeding or injury	Patient takes measures to reduce bleeding or injury