Jerry Williams, 62 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
x Gas Exchange
x Clinical Judgment
x Patient
... [Show More] Education
NCLEX Client Need Categories Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
9 Management of Care 17-23% 9
9 Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% 9
Psychosocial Integrity 6-12% 9
Physiological Integrity
9 Basic Care and Comfort 6-12% 9
9 Pharmacological and Parenteral Therapies 12-18% 9
9 Reduction of Risk Potential 9-15% 9
9 Physiological Adaptation 11-17% 9
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2
History of Present Problem:
Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II
diabetes. Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because
he had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with
increased difficulty breathing when he woke up and his wife called 911.
Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory
wheezing bilat. He was placed on oxygen by facemask and albuterol nebulizer administered with some improvement in
his breathing. His RR is now 24 upon arrival to the emergency department ED). His initial labs have resulted; creatinine
of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7) and BNP 944 (last adm. 322). Jerry is given furosemide 40 mg IV in the ED
and had 800 mL urine output in the last hour. He is admitted to cardiac telemetry, and you are the nurse responsible for his
care.
What data from the present problem do you NOTICE as RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
What is the RELATIONSHIP of his past medical history and current medications? Why is your patient receiving these
medications? (Which medication treats which condition? Draw lines to connect)
Past Medical History (PMH): Home Medications:
Hyperlipidemia
Hypothyroidism
Type II diabetes
Diastolic heart failure
Chronic kidney disease stage III
Furosemide 20 mg PO every morning
Atorvastatin 40 mg PO at bedtime
Metoprolol 50 mg PO BID
Levothyroxine 112 mcg PO daily
Exenatide microspheres 2 mg subq. weekly
Nursing Assessment Begins:
Current VS: Most Recent in ED: P-Q-R-S-T Pain Assessment:
T: 98.2 F/36.8 C (oral) T: 98.8 F/37.1 C (oral) Provoking/Palliative:
P: 88 (reg) P: 92 (reg) Quality: Denies
R: 24 (reg) R: 24 (reg) Region/Radiation:
BP: 142/76 BP: 148/80 Severity:
O2 sat: 93% 4 liters n/c O2 sat: 94% 4 liters n/c Timing:
1. obese, type II diabetes, Diastolic
heart failure
2.shortness of breath with activity/
increased difficulty breathing when
he woke up
3.more swelling in his lower legs
4. High RR and BP and low O2 sat
5. high creatine and BNP labs
1. shows that patient was not in the best health before these
problems began
2.shows that there is something going on with his gas
exchange
3. could be a problem with purfusion, possible DVT
4. proves that hes is having difficulty breathing and his heart
is trying to pick up the slack
5. increase risk for kidney and heart failure
This study source was downloaded by 100000852290574 from CourseHero.com on 12-05-2022 12:43:30 GMT -06:00
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3
What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND:
RELEVANT Assessment Data: Clinical Significance: TREND:
1. INTERPRETING relevant clinical data, what is the primary problem? What primary health-related concept(s)
does this problem represent? (Management of Care/Physiologic Adaptation)
Current Assessment:
GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting
comfortably.
NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both
upper and lower extremities bilaterally.
HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white
bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and
moist.
RESPIRATORY: Breath sounds coarse crackles in bases bilat.with equal aeration on inspiration and
expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort.
CARDIAC: Pale/pink, warm & dry, 2+ pitting edema in feet and ankles, heart sounds regular, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart
tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no
abnormal beats or murmurs. Unable to assess JVD due to obesity/thick neck
ABDOMEN: Abdomen round, soft, and nontender. BS + in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3
seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin
turgor elastic, no tenting present.
Problem: Pathophysiology of Problem in OWN Words: Primary
Concept(s):
.
Pulse decreased
BP decreased
O2 sats decreased by 1%
He is more calm, less work on heart
Less work on heart trying to pick up slack
may need O2 adjusted
work on heart is
decreasing, may
need re-evaluated
for a higher liter
Respiratory: crackles
Cardiac: 2+ pitting edema
Fluid is in lungs
fluid in cells tissues
increased buildup
of fluid
Pulmonary
embolism
Cardiac,
Perfusion,
respiratory
Patient had a DVT, which was the cause for the swelling he noticed in his legs. The DVT dislodged and
moved up to lungs creating a pulmonary embolism. This is the cause of the shortness of breath and
crackling lung sounds
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4
2. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND?
(Management of Care)
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Medical Management: Admission Medication Orders
Care Provider Orders: Mechanism of Action: Expected Outcome:
Administer the following home
medications:
Atorvastatin 40 mg PO daily
Metoprolol 50 mg PO BID
Levothyroxine 112 mcg PO daily
New order:
Heparin 5000 units subq. BID
Medication Administration
1. IdeQWif\ Whe ³UighWV´ of safe medication administration?
Promote patient activity
Assist patient to sit up in bed,
chair, or go for short walks
The movement will prevent other clots from
forming. Immobilty will increase the risk of
more clots and pneumonia.
Sitting up will allow
for easier breathing
and other clots will
not develop.
A:inhibits rate-limiting step in cholesterol
biosynthesis by competitively inhibiting
HMG-CoA reductase
M:blocks response to beta-adrenergic
stimulation
L: Synthetic T4; increases thyroid actions
H: inhibits the conversion of prothrombin to
thrombin
A: lower lipid levels
M: Lower the risk of
heart attack
L: raise the level of
tyroid hormone
H: decreases the
clotting ability, and
can reduce the size
of a clot [Show Less]