Admission assessment for Mr Glenn, a 78-year-old man
Question – Admission assessment for Mr Glenn, a 78-year-old man
Admission assessment for Mr Glenn, a 78-year-old man
The nurse is performing an admission assessment for Mr. Glenn, a 78-year-old man with a history of cardiovascular disease and hypertension. He takes 20 mg of furosemide and 5 mg of Zestril daily. He was seen in the physician’s office today reporting swelling in his feet, shortness of breath while playing golf, awakening at night unable to catch his breath, and “feeling” his heart beating in his chest.
Mr. Glenn’s blood pressure is elevated, and there is no auscultatory gap. A third heart sound is present. His chest x-ray shows cardiac hypertrophy. There are adventitious sounds in both lower bases. He has gained 10 pounds in the past 2 weeks. A urinalysis is normal. His ECG is normal with evidence of slight cardiomyopathy.
a. What could be the problem?
b. What do you assess? Name minimum of five assessments and the reason to do it.
c. What would you implement? Name minimum of five implementations and the reason to do it.e.
d. What is your primary and secondary nursing diagnosis for this patient? Utilize the PES format (problem, etiology, S&S)
e. What is your goal for this patient? Goal must be S.M.A.R.T (Specific, Measurable, Attainable, Realistic, and Timely)
Answered by Expert Tutors
a. All the signs indicate that the patient has heart failure. The heart failure precipitated the patient’s difficulty in breathing (Parati et al., 2016). The symptoms are consistent with this finding, because he has palpitations, difficulty in breathing while performing a small task, and paroxysmal nocturnal dyspnea, which wakes him up night to catch his breath.
b. The first assessment is the patient’s breathing rate in order to establish the efficiency of his respiration. The next assessment is to check pedal edema in order to quantify level of fluid retention due to heart failure. A septic screen is also important in order to diagnose any infection. The patient would also be assessed for any fevers which might indicate infection. Finally, patient’s blood pressure records for previous visits would be compared with the current findings in order to diagnose the changes so far.
c. The first step would be to admit the patient for further observation. I would also put the patient on oxygen in order to improve his oxygen saturation levels. I would also go through the septic screen results and note any significant outcome. I would also direct on healthy diet with less salt to reduce edema, and perform a thorough respiratory system exam for proper diagnosis.
d. Primary diagnosis: Difficulty in breathing related to heart failure as evidenced by adventitious sounds in both lower bases.
Secondary diagnosis: Hypertension related to heart failure as evidenced by cardiomyopathy
e. I will provide ventilator support to ensure the patient has an oxygen saturation of above 90 percent and ensure that the patient can maintain that concentration even on room air within 24 hours.
Reference
Parati, G., Lombardi, C., Castagna, F., Mattaliano, P., Filardi, P. P., & Agostoni, P. (2016). Heart failure and sleep disorders. Nature reviews Cardiology, 13(7), 389.
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