Question

At 1400 hrs. on Tuesday, Mr. Adebo Ikeme, an 83 year old Black male was admitted to your floor with complaints of significant SOB when taking the stairs to his 3rd floor walkup in Brooklyn.  He is 5’10” tall and weighs 145 lbs. He has a 15 year history of HTN but has not been seen for follow-up in several years. He states that the breathing problem started about a year ago but got worse this week.  His LE evidence 3+Edema to the middle of his shins.  Mr. Ikeme states that he gets up several times a night to use the bathroom – but only has “a little bit of pee” each time. As he speaks to you, you note that his pupils are bilaterally cloudy and his dark brown irises have a distinct pale blue ring around the perimeter.   Admission vital signs:  BP  169/102, Pulse 88, Resp 18 & temp. 96.8°F.

IDENTIFY KEY FINDINGS/SIGNIFICANCE AND NURSING IMPLICATIONS

Answer 1

The key findings in the patient are

• Shortness of breath :This indicates that the cardiac system is involved in this SOB .as the patient is unable to sleep in the night time
• Know case of hypertension:which is uncontrolled can lead to stroke and other CVS issues easily
• Poor treatment adherence and follow up .This could be probably because of old-age, socioeconomic factors, family ,etc. ,
• Edema in lower extremities signifies alterations in the fluid balance and retention of fluid in the lower extremities
• Elevated blood pressure is typical indicator of CVS disease
• Cloudy, blue tinted eye results because if deposition of cholesterol in the eye.

The nursing implications for this patient are

• Monitor vital signs ,as this is the baseline data to identify any problems and plan for care
• Assess the respiratory status and administer oxygen if the oxygen saturation is low .
• Assess the cardiac functions by doing the ordered diagnostic procedures and lab tests
• Administer medication to lower the blood pressure
• Assess the vision acuity level as per order to know the ability of the patient to see and plan for care appropriately
• Monitor intake and output chart to know the fluid balance and make necessary corrections
• Provide a cardiac diet or low sodium diet to keep blood pressure under control through diet
• Encourage the patient to be physically active ,do simple daily exercise to improve the heart functions.