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Mrs. Edwards, a 75 year old women, was admitted to the medical unit with complaints dyspnea on exertion.
Subjective data:
-Had a severe myocardial infarction at 62 years of age.
-Has experienced increasing dyspnea on exertion during the last 3 years.
-Recently had a respiratory tract infection, frequent cough, and oedema in legs 2 weeks ago.
-Has to sleep with head elevated on three pillows.
-Does not always remember to take medication.
Objective data:
-In respiratory distress, use of accessory muscles, respiratory rate 36 breaths/min.
-Heart murmur.
-cyanotic lips and extremities.
-Skin cool and diaphoretic.
-Venous leg ulcer on left ankle.
-Bloated abdomen.
Physical Examination:
-Pulse full and bounding= 92 bpm, blood pressure 142/86 mmHg.
-General strength of 4/5 ( 80 % of normal)
Diagnostic studies:
-White cell count ( WBC 15 * 10 /L), BNP normal ( 100 pg/ml ) ; troponin I normal ( 0.01 ng/ml) .
-Chest X-ray result: Cardiomegaly with right and left Ventricular Hypertrophy ; fluid in lower lung fields.
-Ejection fraction 25%.
Collaborative data:
– Digoxin 0.25 mg by mouth once daily.
– Frusemide 40 mg IV twice daily.
– Potassium 40 mmol/L by mouth twice daily.
– Peridopril 8 mg by mouth once daily.
– Low sodium diet.
– Oxygen 6 L/min via Hudson Mask.
– Daily weight.
– Cardiac enzymes every 8 hours * 3.
In addressing this case study you are required to present your paper under four headings:
* Patient History.
– Present a short patient history ( approximately 250 words ). This history should demonstrate the complexities of your clinical specialty area ( Intensive Care Unit ). While the patient problems do not have to be dramatic, it is expected they will provide with an opportunity to demonstrate under the following three assignments headings how you address issues in your selected area of nursing practice ( intensive care unit) using sound clinical judgment, critical analysis and planning to ensure the best patient outcomes.
*Signs and/or Symptoms:
– Identify the pertinent signs and symptoms which you believe contributed to the patient’s key issues or problems. You are required to use current literature to justify why these signs and symptoms were of particular significance in this instance and how they contributed to ( or allow this identification of ) the key patient issues or problems.
* Key issues or problems:
-The key patient issues or problems may be medical and or nursing. An important consideration here is the prioritization of key patients issues or problems. if there are multiple issues which might be considered, make sure it is the most important issues which you identify. Literature should be used to demonstrate the seriousness of these issues and problems they may create for the patient.
*Care recommendations:
-Given the problems you have identified what is the best approach to patient care which should be taken in this instance. As with assessment 1 you are required to use evidence to argue why you have chosen to make the care recommendations you have (i.e. do not use state in your assignment this is what we should do but rather construct an argument and state something like both Burns and Smith supported management X. While Groves believes the best approach is Y, it is likely a combination of X and Y with the addition of Z will provide the best outcomes owing to ….). you must draw upon current literature to support your argument.
The word count is 3000 words ( +/- 10 %). Key issues or problems and care recommendations will constitute the majority of your word count.
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