The patient had laceration and abrasions on both hands, knuckles, knees and a laceration on his head. The patient had some bleeding on his face and the nurse clean it up as we assess him. The patient had some x-rays all over his body for any broken bones and the x-rays detected a fracture on his left side of his head. The nurse also told me to give ventilation to the patient. The vital signs are follow B/P-165/97,149/90,143/87,139/79, RR-10,12,12,13,15, pulse 116,109,105,106.…
Admitting diagnosis: Transient Ischemic Attack Course of current hospitalization to date: Patient was given 100% supplemental oxygen via nasal cannula. 12-lead electrocardiogram indicating…
A patient named RG has ischaemic heart disease with two previous myocardial infarctions (MIs) is admitted to ICU after undergoing coronary artery bypass grafting. After surgery, his preoperative ejection fraction was 45%. He also has controlled hypertension and hypercholesterolaemia. He needs mechanical ventilation and pulmonary artery catheter in place. His blood pressure and urine output have fallen after one hour admission to the ICU.…
Mr. Jax Marlboro Respiratory Care Pharmacology Fall 2015 Joni Sims Presenting History and Physical: Mr. Marlboro, a 65 year old African American male who is being seen in the emergency room with complaints of fatigue, shortness of breath, and wheezing while trying to accomplish simple daily task. He also complains of a cough that is becoming more frequent and persistent. Mr. Marlboro has a history of asthma as a young adult and was diagnosed with hypertension at the age of 40. Mr. Marlboro stated that he has been a smoker since the age of 18 and smoked 1 pack of cigarettes a day until he quit 3 years ago. He has not been treated for his asthma in several years and assumed that he grew out of it.…
REASON CHIEF COMPLAINT: Heart failure. Coronary artery disease. Atrial flutter. BLANKLINE This patient had an acute MI _____ and underwent three vessel coronary artery bypass grafting at that time.…
Database and Assessment Table 1 – Physical Nursing Assessment Data GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg. SKIN/HAIR/NAILS: Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain.…
Nurse Home Visit Assessment and Education for Sallie Mae Fisher Sallie Mae Fisher, a recently widowed 82-year-old female, was discharged from the hospital last Saturday after a three day stay related symptoms of congestive heart failure (CHF) exacerbation, including dyspnea, chest pain, and a weight gain of 8 pounds. This was Sallie’s fourth hospitalized in the past six months for the same diagnosis. Her other history includes hypertension and atrial fibrillation (AF). This paper will explore problems related to her CHF, physical assessment, and psychological and spiritual well-being identified during a recent home visit. Intervention to assist Sallie to better manage her health and reduce her hospitalizations will be discussed.…
The patient is a 56 year old Bangladesh male came by ambulance due to sudden onset of shortness of breath at 3 o’clock in the morning when he woke up to go to the washroom. The patient also has chest pain, nausea and vomiting, fever and worsening orthopnea The patient is having dementia, hypertension and ESRF stage 4. However, patient reused HD and was under nephro clinic, but planned for palliative management. The patient had been admitted to the hospital due to the same presenting complaint for several times.…
Upon admittance he was semicomatose and confused. He had suffered abrasions to his face, a laceration to his left thigh and bruising to both thighs. His extremities were cold and sweaty, his blood pressure was 90/60mmHg and his pulse rate was 130beats/min. The paramedics had also reported a litre of blood had been lost at the scene. In order to rectify this, 3L of saline was administered.…
Introduction Perfusion is a very important aspect to the human body. Perfusion is defined as the flow of blood through arteries and capillaries that deliver oxygen and nutrients to the cells and removing cellular waste from the body (Giddens, 2013, p. 148). For us to maintain optimal perfusion, we need are heart to generate sufficient cardiac output. This means transporting the blood through patent blood vessels to supply the tissues throughout the body. Impaired perfusion may occur when the blood supply is reduced or completely interrupted (Giddens, 2013, p. 148).…
The patient J.V., had the diagnoses of shortness of breath, diabetes, obesity hypoventilation, and respiratory failure. His readings kept being high for blood glucose during my shift; ABG showed pH of 7.38, PCO2 of 79, PO2 64, CO2 42 mmol/L, and oxygen saturation of 97%. The morning of my clinical shift, his blood glucose was at 215mg/dL, the patient had cough, weakness, fatigue, and shortness of breath. He was on insulin Levemir, bronchodilators, antihypertensives, blood thinners, bronchodilators, and BiPAP therapy. After insulin was administered, he reported he felt “mareado (dizzy)” and didn’t know…
Administering additional doses and combining the medication might have caused Mr. B. to become over sedated. Over sedation can result in decreased oxygen level and lower blood pressures (58/30 and 79%) as in the scenario. The potential for life threatening conditions such as the ventricular fibrillation and respiratory distress or arrest can result from over sedation, as…
This is to provide immediate respiratory care if the patient’s airway is compromised (Higginson, Jones & Davies, 2011). This is a low priority. B. BREATHING – Respiration is altered due to left ventricular failure. The patient is tachypnoeic due to an increased pressure in the pulmonary veins that will lead to pulmonary congestion that lessens pulmonary compliance, which raises the respiratory rate.…
It was my third day caring for the patient and we had received orders on how to increase his tube feedings as long as he could tolerate it. The patient never complained of pain during my previous shifts, but suddenly during the shift, the patient started complaining of stomach pain. He had an increase in blood pressure, heart rate, and breathing. Me and my preceptor contacted the patient’s physicians and the RRT. Test were ordered and we closely monitored the patient.…
Patterns of Illness and Wellness Nadejda Kan NURS 301 School of Professional Studies CUNY FALL 2016 Abstract This paper addresses the patterns of illness and wellness of a 75-year-old woman presented to the Emergency Department at New York Medical Center with complaints of chest pain. Patterns of Health and illnesses are influenced by different factors such as age, gender, geographical location, social status, genetics, familial history, education and environment. Some of health behaviors that include physical activity, tobacco use, alcohol consumption and diet choices affect the patterns of health and illnesses.…