Introduction
Norma James has a history of Type 2 diabetes, hypertension, atrial fibrillation and a past stroke. Ms. James came in to the clinic today with complaints of shortness of breath. A nursing student is working with me today. She currently is learning how to complete focused histories as well as patent assessments in her assessment class. Together we will take Ms. James’s history, complete an assessment, document our findings, develop a plan of care and education plan for her.
Assessment
Our Assessment findings include:
• Onset – on and off for four months, comes and goes, worse lately.
• Duration – shortness of breath on and off for few years almost constant with little activity the past four months. Recovery time one hour. Feet swollen more the past two months unable to get the swelling down.
• Characteristics – feels like she “can’t get enough air”. Feet are swollen mostly around the ankles sometimes she can not get her shoes on. Gained 10 pounds.
• Aggravating factors – shortness of breath-activity. Edema worse after out of bed.
• Alleviating factors – shortness of breath – sitting. Edema nothing
• Other background information- out of supplies to take …show more content…
James. She has been diagnosed with class two heart failure. In a discussion with my student we talk about our assessment and our findings. We discuss the patient’s cardiac issues which includes a fast irregular heart beat the student recognize this as atrial fibulation (afib). While in afib the patient’s heart is not beating effectively. In Ms. Jones’s case her afib is combined with congestive heart failure which is causing the fluid overload resulting in enema in her legs, fluid in her lungs and shortness of breath. The doctor has prescribed a diuretic, Lasix which will cause the patient to have frequent urination and rid the body of excess fluid. I explain, potassium is lost with urine therefore, we are also administering a potassium
Norma James has a history of Type 2 diabetes, hypertension, atrial fibrillation and a past stroke. Ms. James came in to the clinic today with complaints of shortness of breath. A nursing student is working with me today. She currently is learning how to complete focused histories as well as patent assessments in her assessment class. Together we will take Ms. James’s history, complete an assessment, document our findings, develop a plan of care and education plan for her.
Assessment
Our Assessment findings include:
• Onset – on and off for four months, comes and goes, worse lately.
• Duration – shortness of breath on and off for few years almost constant with little activity the past four months. Recovery time one hour. Feet swollen more the past two months unable to get the swelling down.
• Characteristics – feels like she “can’t get enough air”. Feet are swollen mostly around the ankles sometimes she can not get her shoes on. Gained 10 pounds.
• Aggravating factors – shortness of breath-activity. Edema worse after out of bed.
• Alleviating factors – shortness of breath – sitting. Edema nothing
• Other background information- out of supplies to take …show more content…
James. She has been diagnosed with class two heart failure. In a discussion with my student we talk about our assessment and our findings. We discuss the patient’s cardiac issues which includes a fast irregular heart beat the student recognize this as atrial fibulation (afib). While in afib the patient’s heart is not beating effectively. In Ms. Jones’s case her afib is combined with congestive heart failure which is causing the fluid overload resulting in enema in her legs, fluid in her lungs and shortness of breath. The doctor has prescribed a diuretic, Lasix which will cause the patient to have frequent urination and rid the body of excess fluid. I explain, potassium is lost with urine therefore, we are also administering a potassium