Question

Patient is 88 year old female admitted to the hospital with a two day history of feeling SOB, lightheaded, dizzy, and chest pain. The patient lives in a single family house, and the bedroom and bathroom are located on the second floor. The patient was brought to the ED by the family. The nurse starts to perform the nursing assessment and finds that the patient is only oriented to person. The patient does not report any pain. The vital signs and the laboratory results are recorded as the following:

Temp. 38.1   pulse 98    resp. 32    Blood pressure 122/80   SpO2 with RA at Pulse Ox 89% , weight at 120 pounds (54.54 Kilograms), height 5.4

Na                   148

Cl                    96

Potassium        3.5

Bicarb             39

BUN               50

Creat             1.78

Glucose         124

Hgb              6.6

Hct              21.5

WBC           24.9

Platelets     145,000

Albumin       3.5

ROS:

Negative

PMH:    CAD, CKD, HTN, COPD

PSH: Bilateral knee replacement

Social hx: lives alone, drinks one glass of wine once a day, denies smoking and drug abuse

Allergies:

NKDA

Medications at home: Lisinopril 40 mg once a day, ASA 81 mg once a day, Lasix 40 mg once a day, Advair one puff every 12 hours

Physical Exam:

Awake, confused to time and place, oriented to self

Mucous membranes dry, tongue pink

HEENT: AT/NC, PERRLA, neck supple, no JVD

CV: RRR, Normal S1 S2, no m/r/c heard

Lungs:   Breath sounds vesicular with crackles in the posterior bases

ABD: distended with faint bowel sounds, tender to touch

Extremities: upper and lower extremities with strength at 3/5 for all four extremities

Has 3+ edema in lower legs bilaterally

Skin: small open redden area on left thigh

Diagnostic Exam:

ECG: Normal

2D echocardiogram: LV function at 20%

Answer the following questions:

Identify the abnormal lab tests.         

Identify two nursing diagnosis for this patient.

Identify two nursing intervention for each nursing diagnosis with rationale.

Identify one short term goal for each nursing diagnosis.

Identify one outcome for each nursing diagnosis.

List the medications for the patient.

List the diagnosis test ordered for the patient and the results.

Answer 1

Abnormal lab test:

• Increased sodium (135-145mEq/ l)Hypernatremoa
• Increased BUN(2-7 mg/dl)
• Decreased Hgb (12.1. -15.1 mg/dl) Severely anemic
• Increased WBC(4.5 to 11 *10 to the power 9) Infection
• Decreased EF(above 60%) Heart failure

Nursing Diagnosis:

• Impaired cardiac or tissue perfusion related to anaemia
• Impaired gas exchange due to disease condition

Nursing Interventions:

• Maintain oxygen level with oxygen therapy (0.5L to 2L) to make him breath comfortably to meet the oxygen demand and to prevent dyspnea,use puff
• Transfuse blood very cautiously ,doing so will relieve patients giddiness, light-headedness

Short term Goal

• To make patient get back to normal HB level
• Make her feel comfortable in breathing, administration of nebulization will help

Medication

• Lisinopril: Antihypertensive
• Lasix: Diuretic
• Adavir puff:Beta 2 adrenergic Bronchodilator and corticosteroid

Diagnosis test

• CBC: HB _ Low,WBC_ Very High
• 2D Echo_ EF 20%
• ECG
• Electrolyte ( sodium( increased), chloride, potassium)
• Creatinine: Increased
• Blood Urea Nitrogen: Increased
• Albumin: Normal