CASE STUDY 75 M PK CC SOB,

CASE STUDY 75 M PK CC SOB, Bilateral Lower extremity swelling The patient was admitted last night after having trouble breathing at home. The patient was unable to catch his breath even upon rest. He lives alone, smokes 3 PPD, meth user, and works at Mcdonald’s as a cashier. Diet usually consists of fast food x3 meals. The patient is noncompliant with prescribed meds. States that his parents passed from heart issues years ago. No iso Hx Diabetes, coronary artery disease, COPD, HTN, HLD Ax Penicillin – Vitals 155/90 HR 87 RR 22 O2 86% RA T 98.6 (Previous) 166/91 HR 90 RR 21 O2 85% T 98.6 (Recent) A/O x4, agitated to leave, PERRLA, no facial droop, symmetrical face, Lung sounds crackles, labored breathing, normal heart sounds, S1/S2, normoactive bowel sounds, appetite is normal, decreased urination, wound on left arm, noted pus/drainage at the site, 3x2x2, patient states a spider bit him, Last BM yesterday. He ambulates without assistance normally but has stated weakness recently. The patient repeatedly asks to go downstairs to visit a friend. Pain is 5/10 leg pain. Legs are swollen, Pedal pulses are bounding, cap refill >3, and hard to determine due to swelling. Legs are weeping. – Labs WBC 14 16 HGB 18.1 18.3 HCT 38 38 PLT 300 320 Na 133 132 K 4.5 4.7 BUN 12 12 Creat 1.9 2.1 Pro BNP 5000 6000 Cardiac Enzymes Troponin 0.02 0.02 – Medications Lasix diuretic 20mg PO AM Beta blocker Metoprolol PO 25mg PO BID Entresto Sacubitril / Valsartan PO 1tab AM Plavix Benazipril – Interventions Perform Apply O2 Monitor K (Lasix), Pro BNP Echo EF EKG Assess lung sounds Intake/Output Wound care Abx Education Smoking cessation Lifestyle changes, cardiac diet S/Sx of when to seek medical attention Monitor swelling Monitor daily weights Medication management SMART Goal: Maintain O2 saturation of 95% or greater by the end of the shift. 1) From this case study uses this scenario to write out your assessment data collection (what are the identified abnormal findings observed) 2) What are the analysis data collection? that is what is the cause of the patient’s problem that must be prioritized? 3) As a nurse, what are your planning for this patient? That is develop a list of actions to address the priority hypothesis 4) What is going to be your implementation solution for this patient? That is specific nursing interventions performed during your shift for this patient.

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