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
... [Show More] 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: [Show Less]