The patient is a 57 year old female who went to the Urgent Care due to a complaint of shortness of breath, weakness and leg edema. She was seen by the Urgent Care Physician who advised her that she has fluid overload with severe hypertension and a holosystolic murmur. She was then sent to the ER for further observation. Her religious preference is Catholicism. N.E. has no known allergies. Imaging studies of the chest was done and the imaging studies suggested congestive heart failure, and the patient was then admitted.
N.E. refuses to settle in bed and denies assistance going to the bathroom. She would prefer to sit in the bedside recliner in high Fowler’s position. She stated, “When can I speak with the Doctor regarding my discharge.” N.E. …show more content…
N.E. weight at 87 lbs. and is about 4’11 feet tall. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Moist mucous membranes in oropharynx. Her neck was supple and no carotid bruits. Cardiovascular: sounds was regular rhythm and rate was regular however, positive on Holosystolic murmur at S2 and S4. Abdomen: Normoactive bowel sounds. Soft, non-tender, non-distended, normoactive bowel sounds in all four quadrant. No hepatosplenomegaly. Extremities: No clubbing, cyanosis, 1+ edema bilaterally on the lower extremities. Lungs: Patient’s breathing is clear to auscultate bilaterally, no wheezing, no crackles, and no accessory muscle use. No tenderness to palpation. Skin: Warm, dry, well-perfused. No rashes or other lesions, and skin is intact. Neurologic: Alert and oriented x 4. No pain. Pupils are equal and reactive to light. Patient was able to communicate well. Sensation intact in all extremities. Genitourinary: Clear, yellow urine. No dysuria, hematuria, frequent urination. Endocrine: Patient denies any fever, and fever. However, per patient she has HTN history and anemia issues. Psychological: denies suicidal thoughts. Patient admission diagnosis was Congestive Heart …show more content…
Patient will participate in activities that reduce the workload of the heart. Monitor patient’s abnormal heart and lung sounds. Monitor patient’s blood pressure and pulse since patient has history of shortness of breath and hypertension. Assess patient’s mental status and level of consciousness since shortness of breath can lead to confusion, lethargy, and altered consciousness due to poor perfusion and oxygenation. Ineffective breathing pattern related to CHF as evidenced by shortness of breath. Patient’s respiratory pattern will be effective without causing fatigue and weakness. Educate patient to use relaxation techniques and breathing techniques. Assess patient’s emotional response when walking or ambulating. Observe and monitor patients breathing pattern for shortness of breath, pursed-lip breathing, and use of accessory muscles. Monitor patient’s vital signs to gain baseline data. (Lewis, Bucher, Dirksen, Harding, & Heitkemper, 2014) While taking care of the patient during my shift, patient was able to walk to the bathroom without any assistance from me or other nurses. She did not want to use the walker or any other assistive devices. She also refused a sponge bath, she wanted to take a shower on her own, however, she wanted someone outside the door to check on her from time to time to make sure she was ok and that’s what I
N.E. refuses to settle in bed and denies assistance going to the bathroom. She would prefer to sit in the bedside recliner in high Fowler’s position. She stated, “When can I speak with the Doctor regarding my discharge.” N.E. …show more content…
N.E. weight at 87 lbs. and is about 4’11 feet tall. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Moist mucous membranes in oropharynx. Her neck was supple and no carotid bruits. Cardiovascular: sounds was regular rhythm and rate was regular however, positive on Holosystolic murmur at S2 and S4. Abdomen: Normoactive bowel sounds. Soft, non-tender, non-distended, normoactive bowel sounds in all four quadrant. No hepatosplenomegaly. Extremities: No clubbing, cyanosis, 1+ edema bilaterally on the lower extremities. Lungs: Patient’s breathing is clear to auscultate bilaterally, no wheezing, no crackles, and no accessory muscle use. No tenderness to palpation. Skin: Warm, dry, well-perfused. No rashes or other lesions, and skin is intact. Neurologic: Alert and oriented x 4. No pain. Pupils are equal and reactive to light. Patient was able to communicate well. Sensation intact in all extremities. Genitourinary: Clear, yellow urine. No dysuria, hematuria, frequent urination. Endocrine: Patient denies any fever, and fever. However, per patient she has HTN history and anemia issues. Psychological: denies suicidal thoughts. Patient admission diagnosis was Congestive Heart …show more content…
Patient will participate in activities that reduce the workload of the heart. Monitor patient’s abnormal heart and lung sounds. Monitor patient’s blood pressure and pulse since patient has history of shortness of breath and hypertension. Assess patient’s mental status and level of consciousness since shortness of breath can lead to confusion, lethargy, and altered consciousness due to poor perfusion and oxygenation. Ineffective breathing pattern related to CHF as evidenced by shortness of breath. Patient’s respiratory pattern will be effective without causing fatigue and weakness. Educate patient to use relaxation techniques and breathing techniques. Assess patient’s emotional response when walking or ambulating. Observe and monitor patients breathing pattern for shortness of breath, pursed-lip breathing, and use of accessory muscles. Monitor patient’s vital signs to gain baseline data. (Lewis, Bucher, Dirksen, Harding, & Heitkemper, 2014) While taking care of the patient during my shift, patient was able to walk to the bathroom without any assistance from me or other nurses. She did not want to use the walker or any other assistive devices. She also refused a sponge bath, she wanted to take a shower on her own, however, she wanted someone outside the door to check on her from time to time to make sure she was ok and that’s what I