Nursing
Name:__________________________________________________
Data Collection:
Patient History
1. What is the relationship of the patient’s past medical history and his current medications? Answer
a.
and
b.
and
c.
below. (3 points each = 12 pts total)
a. List the medication’s therapeutic classification that is appropriate to the condition from the patient’s medical history.
b. Describe the therapeutic action of the medication (e.g. this medications blocks calcium and allows vasodilation). Use your own words.
c.. Of the medications listed in the right hand column, identify the condition(s) that it is treating from the list on the left column. There may be more than one answer. (In other words, why is this patient taking this medication?)
|
Past Medical History for Mr. Hart: Hypertension Heart Failure Hyperlipidemia Myocardial infarction Coronary Artery Disease |
Home Medications: simvastatin/Zocor 20 mg po daily a. b. c. lisinopril/Prinivil 10 mg po daily a. b. c. acetylsalicyclic acid 81 mg po daily a. b. c. eplerenone/Inspra 25 mg po daily a. b. c. |
Data Collection:
Patient’s Symptoms and Diagnostic Tests
2. What is the relationship between this patient’s primary symptoms and his identified problem of heart failure?
(Review pathophysiology and how it influences the patient’s symptoms. Explain what is happening physiologically to this patient and how it is resulting in his symptoms. Be specific and complete.) (a. 2 points & b. 2 points = 4 pts total)
|
Primary Symptoms: a. Has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He is now becoming SOB at rest, experiencing chest pain with exertion, and is more fatigued and occasionally dizzy. b. Has had difficulty getting his shoes on the last month because of increased swelling around his ankles. His weight has increased from 255 lbs. to 264 lbs. over the last 7 days. |
Pathophysiology / relationship to primary symptoms: a. b. |
3. What is the relationship between this patient’s relevant vital signs and the identified primary problem of heart failure? (a. and b.: 3 points each = 6 points total).
|
Relevant Vital Signs: a. Heart rate and character What is normal: The patient’s data (rate, character): b. Respirations: Rate and lung sounds What is normal: Rate: Sounds: The patient’s data: Rate: |
Relationship to Heart Failure: (What is causing the abnormality in a. b. |
4. What is the relationship between this patient’s diagnostic tests and his identified primary problem of heart failure? (a., b., & c. = 3 points each and
d.
2 points = 11 total pts)
|
Diagnostic test results: a. BNP What is normal: The patient’s data: b. Ejection fraction What is normal: The patient’s data: c. Troponins What is normal: The patient’s data: d. Electrocardiogram The patient’s data (identify the rhythm): |
Relationship to primary problem of Heart Failure or to the patient’s symptoms: (Why were these tests ordered? What do the tests reveal about this patient’s condition? What do the tests mean for this patient?) a. b. c. d. |
Diagnosis/ Identifying the problem
(1
point)
5. Based on the data collection findings, the primary medical diagnosis for Mr. Hart is:
· An exacerbation of heart failure
What is the primary Nursing Diagnosis or the primary physiological problem for this patient?
________________________________________________________________________
Interventions
6. What is the relationship between the healthcare provider’s prescriptions and the patient’s primary problem of heart failure? (a.- f., 2 points each = 12 pts)
(How do these treatments impact this patient at a physiological level to help resolve his heart failure or its symptoms?)
HCP Prescription:
a. Daily weights, I & O, anti-embolism stockings, fluid restriction
b. Oxygen therapy
c. Sodium, potassium, fat, and cholesterol restriction
d. The daily dose of eplerenone/Inspra
e. The one time increased dose of furosemide/Lasix
f. The consult for possible cardioversion
How it helps resolve primary problems associated with Heart Failure:
a.
b.
c.
d.
e.
f.
Evaluation
(4 points, a.-d, 1 point each)
7. The patient is stabilized and ready for discharge.
Explain the classification, purpose, and intended therapeutic effect of adding warfarin/Coumadin to Mr. Hart’s medications: (2 points)
a. Classification of warfarin and its purpose for Mr. Hart:
b. In reviewing Mr. Hart’s medications, what should be brought to the attention of the HCP?
Evaluation, cont.
In applying the professional concept of Evidence-based Care, explain what follow-up activities and observations need to be addressed to promote health and wellness for Mr. Hart, even with his chronic condition of heart failure.
Be specific and complete, citing at least 2 actions. (2 points).
c.
d.
Adapted with permission from© 2011 Keith Rischer/www.KeithRN.com
NURS 1410
Developing Critical/Clinical Thinking by Identifying Relationships in a Patient with Cardiovascular Conditions
Adapted and used with permission
Credits: Dara Lanman, MSN, RN, CNE
Keith Rischer 2011
Christina Wilson
You have been assigned to your patient this am and have been given report. Go to the Patient’s chart and review the most recent information regarding this patient.
Go to patient’s room
Patient’s Chart
Patient’s Chart (click on what you want to review in your patient’s chart.)
Vital Signs
Patient History
Diagnostic Tests
Physician Orders
MAR
Patient History
Patient’s Chart
Main
Mr. Hart, 60 years old, was diagnosed with hypertension and CAD three years ago after experiencing a left anterior MI. Two years ago, his condition worsened and he was diagnosed in early stage heart failure. Today, he comes to the clinic when he becomes concerned that he is becoming SOB at rest, is experiencing episodes of chest tightness, has developed a persistent cough, and is increasingly fatigued with occasional dizziness. He reports that he is noticing shortness of breath on exertion and also some chest discomfort when he exerts himself. He has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He complains of difficulty getting his shoes on the last month because of increased swelling around his ankles. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. over the last 7 days. He admits that he sometimes forgets to take his medications every day. The clinic healthcare provider recognizes that Mr. Hart needs acute inpatient care and coordinates a direct admission to the hospital.
Past Medical History: Hypertension, Hyperlipidemia, CAD, MI three years ago with secondary heart failure
4
Diagnostic Tests:
Main
Patient’s Chart
Lab Today Past
BNP 510 300
Troponins Negative
Cholesterol 210 260
Chest x-ray: bilateral diffuse infiltrates consistent with pulmonary edema
Echocardiogram:
Current ejection fraction is 39% with the past ejection fraction at 47%
Electrocardiogram:
Temp HR RR Lung Sounds BP O2 Saturation
0700 98.6 F (oral) 126 – irregular, bounding 28, regular, labored Crackles both lower lobes; cough noted 150/90 90% on 3L Oxygen per nasal cannula
Main
Patient’s Chart
Main
Patient’s Chart
Health Care Provider Prescriptions:
Oxygen at 3 liters/minute per nasal cannula
Place on pulse oximeter
Strict intake and output, daily weights
Apply anti-embolism stockings
Diet: Sodium-restricted, potassium-modified, low-fat, low cholesterol
Fluid restriction to 1800 mL PO daily
Consult with Cardiac Electrophysiology for possible cardioversion
Furosemide 60 mg one time oral dose now (STAT)
Begin TODAY warfarin 3 mg. PO
Continue home meds
Medication 0700-1500 1500-2300 2300-0700
simvastatin 0900
20 mg po daily
lisinopril 0900
10 mg po daily
acetylsalicylic acid 1300
81 mg po daily
eplerenone HOLD TODAY
25 mg po daily
furosemide 0900
60 mg one time oral dose STAT
warfarin
Begin TODAY 0900
3 mg po
Main
Patient’s Chart
8
Neuro
Click on the buttons below to find out your assessment information.
Cardiac/
Respiratory
GI /
GU
General
Click on the buttons below to find out your assessment information.
Anxious; Alert & Oriented
Client states that he feels light-headed and a little dizzy.
Cardiac/
Respiratory
GI /
GU
General
Click on the buttons below to find out your assessment information.
Cardiac – Skin pale, cool to the touch, Pulse bounding and noted to be irregular, 2-3+ pitting edema lower extremities. No JVD noted.
Resp – coarse crackles scattered throughout both lung fields. Labored respiratory effort. Patient sitting upright. Coughing noted. Client states that he feels short of breath.
Neuro
GI /
GU
General
Click on the buttons below to find out your assessment information.
GI – Active bowel sounds in all 4 quadrants. Abdomen soft/non-tender. No appetite. Reports that he had a bowel movement yesterday.
GU – Voiding without difficulty, urine clear/yellow. Reports getting up at night to urinate.
Neuro
Cardiac/
Respiratory
General
Click on the buttons below to find out your assessment information.
Other – Denies pain but expresses that his chest feels “tight”. Slight headache. Skin integrity intact. Appears anxious, restless, and reports dizziness.
First Quetion
Patient’s Chart
Main
Cardiac/
Respiratory
Neuro
GI /
GU