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Posted: September 1st, 2022
CHF nursing situation
Nursing homework Help
CHF nursing situation
Affected person is a 82 12 months outdated male who introduced to the ED at 5am for shortness of breath worsening over the previous day, PMH contains CHF, HTN, hyperlipidemia, CAD s/p cardiac stents in 2014, DM, osteoarthrtis, BPH, despair, CKD st three
Admitted for CHF exacerbation, pneumonia, acute on power renal illness
You obtain him on the ground at 11:30 am, he seems to be alert and oriented, however torpid, states he hasn’t taken any house meds but right this moment, has not eaten but both. Lives at ALF, makes use of walker
Within the ED, he acquired IV furosemide 40mg, 650mg Tylenol, 500mg IV levofloxacin and an albuterol/ipratropium nebulizer remedy
Chosen labs, diagnostics, and orders
WBC
18.2
Hgb
10.four
Okay (potassium)
three.1
creatinine
four.1
blood glucose
308
BNP
8023
Urine – blood
giant
Urine – leukocytes
+three
Urine – tradition
pending
COVID 19 PCR – unfavourable
chest x-ray
bilateral infiltrates, pleural effusions
sputum pattern to be collected
regular sinus rhythm on tele monitor
important indicators
170/64, P55, R23, O2 90% room air, temp 100.four, ht 178cm, wt 90kg
Food plan: cardiac, 1800 ADA, 1 liter free water restriction
Exercise: as tolerated
Strict I&O
house medicines – have all been profiled to MAR
Hospital meds
metoprolol
25mg
BID
albuterol/ipratropium
Q6hrs
amlodipine
5mg
QAM
furosemide IV
40mg
as soon as 6pm
lisinopril
20mg
QAM
levafloxacin IV
500mg
Q24hrs
atorvastatin
40mg
QPM
tylenol
650mg
Q6hrs PRN
tamsulosin
zero.4mg
QPM
IV potassium 10 meq
x3
clopidogrel
75mg
QAM
aspirin
81mg
QAM
escitalopram
10mg
QAM
metformin
1000mg
BID
tramadol
50mg
Q8hrs PRN
gabapentin
200mg
BID
temazepam
7.5mg
QHS PRN
Consults pending – cardiology, ID, nephrology
Private historical past
former smoker, stop 35 years in the past
doesn’t drink alcohol
didn’t get flu shot this 12 months
Dialogue
What would you count on breath sounds could also be like (doc this in EHR)?
What would you count on pores and skin situation/decrease extremities to be like (doc this in EHR)?
What interventions would you carry out (security, affected person care, treatment, and so forth)
What else are you involved about when assessing?
Take into consideration inquiries to ask the affected person so you’ve gotten a greater report to offer to consulting suppliers in the event that they name
What does every treatment do? Would you maintain any?
Further Assessment to doc in EHR:
GI – bowel sounds in all quadrants, tender non-tender
GU – famous this in urinal
Dark_urine_due_low_fluid_intake.jpg
Cardiac S1S2, pulses okay in all ext, regular cap refill
HEENT – appears a bit onerous of listening to, head with out wounds, eyes, nostril, oral mucosa okay. Has dentures (higher and decrease)
Resp – appears to cough lots after ingesting water/taking tablets
Ache – no points
IV – left forearm 20g, flushes properly, no leaks
Possessions – has glasses, iPhone, bottle of house tramadol
Retired engineer, married, lives at ALF with partner
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