Question

.The client is a 66 year-old female who weighs 154 lbs and is 5 ft, 4 in tall. She lives with her retired husband. They own their own home and live with their three dogs. The client watches her 3 year-old granddaughter 2 days per week. She saw her MD today, who admitted her to the hospital for her recent weight gain of 15 lbs, shortness of breath with activity, and ankle edema. Per the patient her symptoms have been going on for 1 week. She denies recent serious illness, trauma or surgery.Assessment reveals a well-nourished female who is dyspneic, has crackles in the lower lung fields bilaterally, and has 2+ pitting edema of lower extremities (ankles) bilaterally. Her oral temperature is 99.4 F/37.4 C, and her blood pressure is 166/94. Her atrial heart rate is 99 beats per minute, and regular. Her respiratory rate is 30 breaths per minute and her oxygen saturation is 91% on room air. 1.) Assessment-Specify what is abnormal in the assessment, and which data is a priority for your to address. **What medical diagnosis do you think this patient might have going on? 2.)Nursing Diagnosis-Create 3 appropriate nursing diagnoses by matching the parts below into complete nursing diagnoses (R/T = related to & AEB = as evidenced by): Ineffective Breathing Pattern Decreased Cardiac Output  Risk for Fall  R/T altered contractility  R/T increased respiratory rate  R/T dyspnea with activity and pitting peripheral edema AEB crackles, dyspnea and peripheral edema AEB crackles bilaterally and O2 sat 91%(Problem) (Etiology) (Symptoms)1.)2.)3. )3.) Planning-Identify 3 priority nursing interventions for this client (based on the above nursing diagnoses) 4.) Implementation-Explain how you will implement your 3 priority nursing interventions and whether they are “direct” or “indirect” interventions 5.) Evaluation-Evaluate the previous 4 steps of the nursing process, and talk about what your expected outcomes are for this client at time of discharge Formulate a Concept Map for Client (Medical Diagnosis) (Nursing Dx #1) (Assessment Data)(Nursing Interventions)(Nursing Dx #2)(Assessment Data)(Nursing Interventions)(Nursing Dx #3)(Assessment Data)(Nursing Interventions)

Answer 1

ANSWERS

1.) Assessment-Specify what is abnormal in the assessment, and which data is a priority for your to address. What medical diagnosis do you think this patient might have going on?

Assessment findings are

· Symptoms since 1 week.

• recent weight gain of 15 lbs,
• shortness of breath with activity
• Ankle edema.

.Assessment reveals

• · a well-nourished
• · dyspnea,
• · crackles in the lower lung fields bilaterally,
• · 2+ pitting edema of lower extremities (ankles) bilaterally.
• · oral temperature is 99.4 F/37.4 C,
• · Blood pressure is 166/94.
• · Atrial heart rate is 99 beats per minute, and regular.
• · respiratory rate is 30 breaths per minute
• · Oxygen saturation is 91% on room air.

Abnormal Findings: recent weight gain, dyspnea, crackles, pietting edema, hypertension, tachycardia, tachypnea and oxygen saturation of 91%.

Probable Diagnosis

Patient is showing the features of PULMONARY EDEMA, which might have been developed due to an IMPEDING RIGHT HEART FAILURE.

2.) Nursing Diagnosis-

1. Ineffective Breathing Pattern R/T increased respiratory rate AEB crackles, dyspnea and peripheral edema
2. Decreased Cardiac Output R/T altered contractility AEB increased heart rate of 99/mt and elevated Blood Pressure.
3. Risk for Fall R/T dyspnea with activity and pitting peripheral edema AEB crackles bilaterally and O2 sat 91 %.

3.) Planning-Identify 3 priority nursing interventions for this client (based on the above nursing diagnoses)

Ineffective Breathing Pattern R/T increased respiratory rate AEB crackles, dyspnea and peripheral edema

• · Assess and record respiratory rate and depth at least every 4 hours. Assess ABG levels, according to facility policy.Assess the position that the patient assumes for breathing. Utilize pulse oximetry to check oxygen saturation and pulse rate Inquire about precipitating and alleviating factors.
• · Place patient with proper body alignment for maximum breathing pattern
• · Encourage sustained deep breaths by:Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation and Utilizing incentive spirometer.
• · Restrict fluid intake and Encourage small frequent meals.
• · Provide respiratory medications and oxygen, per doctor’s orders.
• · Stay with the patient during acute episodes of respiratory distress.

Decreased Cardiac Output R/T altered contractility AEB increased heart rate of 99/mt and elevated Blood Pressure.

• Assess heart rate and blood pressure. Check for peripheral pulses, including capillary refill.
• Assess for reports of fatigue and reduced activity tolerance.
• Record intake and output. If patient is acutely ill, measure hourly urine output and note decreases in output.
• During acute events, ensure patient remains on bed rest or maintains activity level that does not compromise cardiac output.

• Risk for Fall R/T dyspnea with activity and pitting peripheral edema AEB crackles bilaterally and O2 sat 91 %.

• Assess age related physical changes that makes at risk of fall.
• For patients at risk for falls, provide signs or secure a wristband identification to remind healthcare providers to implement fall precaution behaviors.
• Move items used by the patient within easy reach, such as call light, urinal, water, and telephone.
• Respond to call light as soon as possible.
• Avoid any activities that contribute to dyspnea.

4.) Implementation-Explain how you will implement your 3 priority nursing interventions and whether they are “direct” or “indirect” interventions

All are direct interventions

· Ineffective Breathing Pattern

• Assessed respiratory rate and oxygen saturation, which determine the condition.
• Providing a sitting position permits maximum lung excursion and chest expansion.
• Small frequent meals in short intervals reduce breathing difficulty associated with eating. Restricted fluid intake to 500 ml/day excluding solid food.
• Stayed with patient during acute episodes.This will reduce the patient’s anxiety, thereby reducing oxygen demand

· Decreased Cardiac Output

• Assessed pulses and BP.Most patients have compensatory tachycardia and significantly low blood pressure in response to reduced cardiac output. Weak pulses are present in reduced stroke volume and cardiac output. Capillary refill is sometimes slow or absent.
• Assessed and found activity intolerance.Fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the patient’s response serves as a guide for optimal progression of activity.
• Intake and output recorded. Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output.
• Activities restricted asrestriction of activity often facilitates temporary recompensation.

· Risk for Fall

• Risk assessed. Older people with weak muscles are more likely to fall than are those who maintain their muscle strength, as well as their flexibility and endurance. Patient has dyspnea also which make her less powerful
• Safety measures like wrist band ensured. Healthcare providers need to acknowledge who has the condition for they are responsible for implementing actions to promote patient safety and prevent falls.
• Items kept at easy reach. Items that are too far from the patient may cause hazard and can contribute to falls.
• Responded to call light as early as possible. This is to prevent the patient from going out of bed without any assistance.
• Avoided any activities that contributed to dyspnea.

5.) Evaluate the previous 4 steps of the nursing process, and talk about what your expected outcomes are for this client at time of discharge.

· : Ineffective Breathing Pattern

Patient demonstrates normal breathing with absence of crackles and peripheral edema.

· Decreased Cardiac Output

• · Patient demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for patient; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain.
• · Patient exhibits warm, dry skin, eupnea with absence of pulmonary crackles.

· Risk for Fall

The individual will relate controlled falls or no falls, as evidenced by the following indicators:

• · Patient will not sustain fall.
• · Patient will relate the intent to use safety measures to prevent falls.
• · Patient will demonstrate selective prevention measures.
• · Patient and caregiver will implement strategies to increase safety and prevent falls in the home.

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