• O• Does the current pandemic create any challenges for working on this particular health behavior? (2 points) • Suggest a short-term goal that you could work on for that behavior (e.g., a goal that you can achieve within a month or less) (4 points)

Religion: Roman Catholic
Address: Malabon
Date of Admission: Aug. 2,2020
Time of Admission: 11:30 PM
Chief Complaint: Shortness of breath
Admitting Diagnosis: CHF

History of Present Illness
The patient is a 60-year-old female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.
Past Medical History
Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity. Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.
Her current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, Duo-Neb inhaled q4 hr PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily
Family History
(+) HPN
(+) Diabetes
(-) Asthma
(-) Cancer
Physical Examination
Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, BMI 40.2, and O2 saturation 90% on room air.
Constitutional: Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.
HEENT:
Head: Normocephalic and atraumatic
Mouth: Moist mucous membranes.
Macroglossia
Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
Neck: Neck supple. No JVD present. No masses or surgical scarring.
Throat: Patent and moist
Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities.
Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. Patient barely able to finish a full sentence due to shortness of breath.
Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses
Admission Order
Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.
CBC
Largely unremarkable and non-contributory to establish a diagnosis.
CMP
Showed creatinine elevation above baseline from 1.08 base to 1.81 indicating possible acute injury. EGFR at 28 is consistent with the chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin this corrected to 9.8 mg/dL. Mild transaminitis present as seen in Alkaline Phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.
Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air indicating respiratory alkalosis with hypoxic respiratory features.
Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure, and in the setting of acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is set.
Influenza A and B: Negative
ECG
Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.
Chest X-ray
Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. Small bilateral pleural effusionsRadiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right
.2nd Day of Admission
The second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion further history was obtained via the patient’s husband. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills. ”Testing was performed to include TSH, free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate for left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion and any hypokinetic area.
TSH: 112.717 (H)
Free T4: 0.56 (L)
TSH and Free T4 values indicate severe primary hypothyroidism
BNP: 187
BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, African American patients more excretion may have falsely low values secondary to greater excretion of BNP.
This test is not that helpful in renal failure due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release.
Repeat arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen. CT chest without contrast was mainly obtained to evaluate left hemithorax especially retrocardiac area.
Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease.
Echocardiogram
The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated.
The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. Dedicated tamponade study was not performed.
Estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated.
The aortic valve is abnormal in structure and exhibits sclerosis. The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present.

1. Conceptualize the pathophysiological alterations distinct to the case.

1. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As you receive a report from the postanesthesia recovery unit, you learn that his medical history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair was successful but complicated by excessive bleeding, and he is receiving IV fluids to compensate. He is widowed, and his three children are scattered throughout the United States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his home clean. (Learning Objective #6)
   1. What data in this scenario are pertinent?
   2. What potential collaborative problem(s) could be applicable in this situation?
   3. Which nursing diagnoses would you expect to be applicable regarding the medical procedures in this situation?
   4. Which nursing diagnoses would you expect to be applicable regarding the nursing/medical history in this situation?
   5. Which nursing diagnoses would you expect to be applicable regarding the discharge planning in this situation?

1. Explain four functions of water in the body.

2. What type of patients are considered more susceptible to fluid overload problems?

3. A patient with inflammation of the cecum is at risk for fluid volume deficit. Explain why this is so.

4. Which two electrolytes play a role in muscle contraction and relaxation?

5. How do the lungs help maintain normal pH?

6. Explain at least two causes of metabolic acidosis and two causes of metabolic alkalosis.

1. Explain four functions of water in the body.

2. What type of patients are considered more susceptible to fluid overload problems?

3. A patient with inflammation of the cecum is at risk for fluid volume deficit. Explain why this is so.

4. Which two electrolytes play a role in muscle contraction and relaxation?

5. How do the lungs help maintain normal pH?

6. Explain at least two causes of metabolic acidosis and two causes of metabolic alkalosis.

1. Describe at least eight factors that contribute to constipation.

2. Explain specifically how opioid analgesics affect bowel elimination.

3. Explain what to do if signs or symptoms of a vagal response are noted during enema administration.

4. What can you do to help prevent CAUTIs when inserting an indwelling catheter?

5. How will you perform a 24-hour urine collection when the patient has an indwelling catheter?

6. Explain how to prevent recurring UTIs in female patients.

Basic concept for ergonomic principles to prevent stress

1) What does “cherry picking” mean in speaking?

2) What is the difference between using any source or a credible source?

3) What is the structure of a simple speech, and what is the relevance of each section?

4) Why do you need to use transitions in your speech and between each section?

Discuss at length strategies for medical surge within a healthcare facility.

A scale can be reliable and yet not valid. Provide an example of such a scale that is different than the one found in the text. Remember that a scale means a type of measure such as personality inventory, a skills inventory, a norming chart. DO NOT PROVIDE AN EXAMPLE OF A SCALE THAT WEIGHS SOMETHING (can you tell that many students have done that in the past?).

Include in your answer why you selected or created this particular example.

Give two reasons why having a high requirement for reporting quality measures for hospital compare is a better option. Thank you

COPD Case Study

Andy Portal is a 68-year-old retired construction worker with a 12-year history of COPD after a 35-pack-year history of smoking. He has not smoked in 9 years. He presents in the emergency department complaining of a sharp pain and redness at his posterior left calf, which is also hot and tender to the touch. The medical diagnosis of deep-vein thrombosis (DVT) is made by contrast venography. The nursing diagnosis is ineffective tissue perfusion: peripheral related to decreased venous circulation in the right leg.

When Andy’s wife asks, “What happens now?”, the nurse explains to them both that the goal is to prevent further clot formation and preventing the clot traveling as in pulmonary emboli. This is accomplished by anticoagulants, anti-embolitic stockings, and warm compresses. The nurse discusses the possible pharmacological treatments and side effects. When Andy’s wife asks, “Why did this happen?”, the nurse explains to them that COPD is one of the risk factors for DVT (Vesa et al., 2009).

Questions. Please answer with APA citations

What is the relationship between COPD and vascular effects?

Describe how COPD can cause pulmonary hypertension.

Describe a pulmonary function test (PFT). What finding is indicative of COPD?

Case Study - Pulmonary Edema

A 60-year-old man was admitted to intensive care unit because of dyspnea and pulmonary vascular congestion. The patient had reportedly been well until seven days earlier,when he began to have dyspnea during moderate exertion. Fourdays before admission, he felt a nonradiating, "heavy" discomfort in the lower retrosternal and epigastric areas when he stooped, bent over, or walked short distances. There was no orthopnea, sweating, nausea, or edema. Patient was admitted to the hospital. BP 150/80 mmHg HR 90-100 bpm. Inspiratory crackles were heard at both lung bases. The abdomen was normal, and there was no peripheral edema. Laboratory tests were performed, levels of CK and CK MB were normal, as was the level of troponin. The levels of urea nitrogen, creatinine,glucose, calcium, magnesium, electrolytes, LFT were normal.

Case study questions -Please answer with APA citations.

In YOUR OWN WORDS - explain the pathopysiology behind pulmonary edema. Pretend you were explaining it to another nursing student (correct terminology please)

What are some nursing interventions that can be directed to help this patient during his hospital stay (identify 3 goals for discharge)?

What is some patient / family education that is likely required for when he goes home?

From   this case study i need the SBAR

L.W., a 20-year-old college student, comes to the university health clinic for a pregnancy test. She has been sexually active with her boyfriend of 6 months, and her menstrual period is now “a few” weeks late. The pregnancy test result is positive. The patient begins to cry, saying, “I don't know what to do.”