NURS 198 Cardiovascular Case Study PDF

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health assessment and promotion cardiovascular case study...

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Course Number: NURS 198

Course Section: BXB

Cardiovascular Case Study

Date: July 11, 2021 Course Title: Health Assessment and Health Promotion Student Name: Lorainne Brito Professor: Peter Shute

NURS 198- Nursing Assessment Cardiovascular Case Study

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Nursing Assessment Cardiovascular Case Study NURS 198 Mr Smith is a 50-year-old man with a history of Hypertension (HTN), CAD Coronary Artery Disease (CAD), Myocardial Infarction (MI) in June of 2019 with stents x 2 placed. The patient was brought in by ambulance (BIBA) presenting to the ED for 10/10 chest pain lasting about 10 minutes after eating dinner with family. Pt chewed 325mg ASA and given nitrogen sublingual 1 mins ago. Pt now with 5/10 chest pain. What are your first 3 priority interventions? 1. Provide oxygen via nasal cannula/mask and placed the patient on a semi-fowler position to ease breathing. 2. Keep reassessing the patient by checking his airway, respiratory effort, heart rate, rhythm, strength of contradiction, skin, nutrition, and elimination. 3. Administration medications per physician orders.

When taking vitals and performing your assessment you find: Patient has been noticing an increase in shortness of breath when doing simple tasks around the house and has noticed some "heart skipping". Physical Assessment: Neuro: AAO x 3, moves all extremities to command, and exhibits equal strength. Pulmonary: Exhibits shortness of breath at rest; lung auscultation reveals bilateral crackles in the bases. GI: Bowel sounds normal; abdomen is non-tender to palpation. GU: Clear yellow urine, no abnormalities. CV: Chest pain, palpitations, pulse irregular tachycardic, nailbeds pink, peripheral pulses strong, 2+ edema in lower extremities Vitals: HR 162 bpm, respiratory rate 30 breaths per minute, BP 200/100 mmHG, temperature 98.4 ℉, weight 250 lbs (note: weight has increased by 15 lb since his last check up 1 month ago).

NURS 198- Nursing Assessment Cardiovascular Case Study

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Medications: Digoxin 0.125 mg PO QD Multivitamin PO QD ASA 80mg PO QD Lopressor 25mg PO QD Plavix 75mg PO QD Diagnostic Studies: CXR: reveals a right lower lobe pleural effusion. Labs: Na-137, K-3.8, Troponin-4.0, BUN-35 mg/dL EKG rhythm strip: +STEMI

Answer the following question: 1) State the subjective data. Patient is a 50-year-old male. Has history of hypertension, coronary artery disease, myocardial infraction with stents x2 placed. Patient is taking Digoxin 0.125mg, multivitamin, ASA 80mg, Lopressor 25mg, and Plavix 75mg all by po qd. Patient stated, he has 10/10 chest pain lasting for 10 minutes in which the pain started after eating dinner with family. Patient also stated, he has been noticing an increase in shortness of breath and some “some heart skipping” while doing his ADLs before the heart attack. After administrating medication patient said his chest pain is now 5/10.

2) State the objective data and state whether each is normal or abnormal. Normal- Neuro: AAO x 3, moves all extremities to command, and exhibits equal strength. Abnormal- Pulmonary: Exhibits shortness of breath at rest; lung auscultation reveals bilateral crackles in the bases. Normal- GI: Bowel sounds normal; abdomen is non-tender to palpation. Normal- GU: Clear yellow urine. Abnormal- CV: Chest pain, palpitations, pulse irregular tachycardic, peripheral pulses strong, 2+ edema in lower extremities Abnormal- Vitals: HR 162 bpm, respiratory rate 30 breaths per minute, BP 200/100 mmHG, weight 250 lbs Normal- temperature 98.4℉ Abnormal- CXR: reveals a right lower lobe pleural effusion. Normal-Labs: Na-137, K- 3.8 Abnormal- Labs: Troponin-4.0, BUN-35 mg/dL Abnormal-EKG rhythm strip: +STEMI NURS 198- Nursing Assessment Cardiovascular Case Study

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3) State at least two nursing diagnoses and your rationale for choosing them.   

Cardiac Output, Decreased. Related to chest pain, shortness of breath, abnormal vital signs, ekg test and lab results. [ CITATION Jen \l 1033 ] Health Maintenance, Ineffective. Related to a significant weight gain. [ CITATION Jen \l 1033 ] Gas exchange, Impaired. Related to pulmonary congestion and severe dyspnea. [ CITATION Jen \l 1033 ]

4) Based on your nursing diagnoses, initiate a care plan, including your interventions and how you will evaluate them, for this patient. Nursing Care Plan: Data Collection (Assessment):     



Patient is a 50-year-old man with a history of hypertension, coronary artery disease and myocardial infarction in where in June 19 stents X 2 was placed. Patient is taking Digoxin 0.125mg, multivitamin, ASA 80mg, Lopressor 25mg, and Plavix 75mg all by po qd. Patient was brought in by ambulance presenting to the ED for 10/10 chest pain lasting about 10 minutes after eating dinner with family. Vital signs: HR 162 bpm, respiratory rate 30 breaths per minute, BP 200/100 mmhg, temperature 98.4F, weight 250 lbs. Neuro: AAO x 3, moves all extremities to command, and exhibits equal strength. Pulmonary: Exhibits shortness of breath at rest; lung auscultation reveals bilateral crackles in the bases. GI: Bowel sounds normal; abdomen is non-tender to palpation. GU: Clear yellow urine, no abnormalities. CV: Chest pain, palpitations, pulse irregular tachycardic, nailbeds pink, peripheral pulses strong, 2+ edema in lower extremities Patient stated he noticed an increase in shortness of breath when doing simple tasks around the house and noticed some heart skipping.

Nursing Problem (Diagnosis):  

Cardiac Output, Decreased. Related to chest pain, shortness of breath, abnormal vital signs, ekg test and lab results. [ CITATION Jen \l 1033 ] Health Maintenance, Ineffective. Related to a significant weight gain. [ CITATION Jen \l 1033 ]

NURS 198- Nursing Assessment Cardiovascular Case Study

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

Gas exchange, Impaired. Related to pulmonary congestion and severe dyspnea. [ CITATION Jen \l 1033 ]

Patient outcome/Goal:   

Advance to a proper diet that consists of low sodium and calories. Patient will have a better understanding about his condition and how he can manage it through patient education. Patient respiratory and pain will be under control.

Interventions:   

Provide oxygen via nasal cannula/mask. Placed the patient on a semi-fowler’s position to ease breathing. Keep reassessing the patient by checking his airway, respiratory effort, heart rate, rhythm, strength of contradiction, skin, nutrition, and elimination.

 Administration medications per physician orders  Consult with a nutritionist.  Follow-up with a cardiologist Evaluation:   

By monitoring his vital signs, the patient will maintain a normal respiratory status, heart rate, and rhythm. By following up with a cardiologist the patient will maintain balance in his daily life activities. By following up with a nutritionist the patient will maintain hemodynamic stability.

NURS 198- Nursing Assessment Cardiovascular Case Study

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References Jensen, S. (n.d.). Nursing Health Assessment: A Best Practice Approach.

NURS 198- Nursing Assessment Cardiovascular Case Study...