Introduction (patient and problem) Explain who the patient is (Age, gender, etc.) Explain what the problem is (What was he/she diagnosed with, or what happened?) Introduce your main argument (What
Rick Maples is a 70-year-old living with his wife in his rural home for 30 years. Together, they have 5 children who have various jobs in the federal. For many years, Rick has been having conflicts with his family over children and other problems. From the diagnosis, he has hypertension and edema which has resulted in building up of fluid in his legs. Further interventions indicate he also has arthritis and problems passing stool as well as urine. Ultrasound also shows that Rick has bladder stone which is 40 mm and it appears that he has developed infections in the urinary system. Rick was rushed for medical intervention after shortness of breath and bilateral swelling. He denies having palpitations, fever, chest pain, chills, and orthopnea. From the family interventions, Rick appears to be keeping a distance from his family and not open about issues affecting him. He has been getting treatment for coronary artery disease, edema, hypertension, moderate aortic stenosis, and hyperlipidemia. Rick smoked and took alcohol in his early life and he has stopped for more than 20 years now. His main problem now is shortness of breath, hypertension and bilateral extremity swelling.
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The main problem of Rick is a generalized imbalance between oxygen supply which results in shortness of breath accompanied by exertion and fatigue. The other problem is the voiding pattern relating to systolic heart failure which causes the urinary problem, increased creatinine and brain natriuretic peptide levels. The patient also has edema, urinary tract infections, and rheumatoid arthritis.
Rick Maples has been admitted due to shortness of breath, hypertension and bilateral swelling Rick’s past medical history includes coronary disease where he had placement of anterior descending artery and hypertension. He has also been receiving medication on hypertension and diuretics to manage edema. Due to arthritis, the patient has been taking medications that help to subside symptoms; this includes painkillers and steroids. Rick Maples has also been using antibiotics when managing infections relating to urinary. He has been using Lasix, Enalapril, levofloxacin, metoprolol, fluoxetine, multivitamin, meloxicam, and painkillers.
Nursing Physical Assessment
The noninvasive blood pressure of the patient is 156/92. Oral temperature 35.7 degrees Celsius, heart rate 65 bpm and in sinus rhythm, on room aim oxygen saturates at 84 percent, respirations 18 bpm. The patient is alert, awake but does not ambulate. There is also equal bilateral weakness in the lower extremities. Heart sounds with grade II systolic and with normal sinus rhythm. Upperparts of the lungs are clear but diminish bilaterally in the base. Shows negative for clubbing, accessory clubbing; the capillary refills in the normal range. Patient voids adequate yellow urine and sometimes with difficulty. Other diagnostic values are WBC 7.5, Hemoglobin and Hematocrit 10.1/29.1, Platelets 191, Sodium 139, Potassium 4.5, Creatinine 1.55 (decreased from 3.61), INR 2.1, Albumin 3.1, Magnesium 2.1, BNP 229.
Rick because of his conditions has been receiving medications that range from antibiotics, analgesics, and diuretics. These include furosemide, simvastatin, nicotine patch, aspirin, fish oil, fluoxetine, amiodarone, vitamin C, docusate, multivitamin, enoxaparin, potassium, levofloxacin, Lasix, metoprolol, and warfarin.
Nursing Diagnosis & Patient Goal
Rick Maples has shortness in the breath that resulting possibly from pleural effusions and heart-related problems. He is also hypertensive and has bilateral swelling in the lower limbs. Since he has a problem passing on urine and sometimes bowel issues, he has developed infections in the urinary tract. The patient also has rheumatoid arthritis which makes him have difficulties in ambulation. The goal is to stabilize the blood pressure, to boost oxygen saturation level, treat urinary tract infections and to manage pain.
The care plan for this patient includes prevention of respiratory decline or shortness of breath, blood pressure management, pain control, renal function promotion, boosting patient’s energy levels, further tests and physiotherapy. Interventions include close monitoring of blood pressure, heart rate, weight loss, and other vital signs. The heart rate is expected to reduce myocardial perfusions which might cause recurrence in arrhythmias. Diuretic medications and antihypertensive drugs will promote myocardial perfusion hence decrease preload (MacGregor & Kaplan, 2016).
Since the patient cannot ambulate properly, physiotherapy is also essential. This will enable the patient to be strong and to promote healthy bones. MRI is also needed to identify the reasons the patient cannot ambulate properly. Because of recurrent shortness in breathing, lung X-ray ought to be done to identify the possibility of pleural effusions that might have been caused by right heart failure or any other related problem. There’s also a need to administer antibiotics relating to urinary infections resulting from problems passing urine.
The patient has to have frequent resting so that he can maximize energy and saturation levels. The slow progression of activities is expected to occur which will prevent exhaustion and myocardial overload (Vimalesvaran & Marber, (2014). The patient’s renal problem is attributed to a heart problem and a possible aortic aneurysm. This prompts the need for promoting effective renal clearance and decrease volume status. They will be a daily assessment of lower limb swelling and weight loss monitoring to ensure the patient is losing water that had accumulated in lower limbs. There is also a need for supplemental oxygen, diuretics medication, lifestyle and dietary monitoring. To manage the renal problem, interventions such as maintenance of sufficient fluids is necessary, this will also prevent cardiac workload in the body (Mohrman & Heller,2018). Since the patient also has arthritis, there is a need to administer painkillers and also steroids that might subside the symptoms.
After the administration of drugs such as Losartan H relating to hypertension, the patient’s blood pressure levels stabilized and stated ranging from 136/89 and 120/80. He also began to saturate at 96 percent which is okay considering the age and the underlying conditions. Regular weight loss assessment indicated that the patient lost 3 kilograms in a day; this is attributed to the administration of diuretics which removed excess water in the body. The patient had pain while passing urine but after the administration of antibiotics, the pain has reduced immensely and the patient passes urine without difficulties. The physical assessment shows bilateral swelling has reduced significantly as well. However, there is a need for more testing to check if there a possibility of blood clotting in the limbs which also contributes swellings. Since the patient has bladder stones, removing this through surgery might be complex since the blood pressure has not stabilized well and the HB levels are not good enough.
The patient feels pain in joints and have problem ambulating, this is as a result of rheumatoid arthritis that has affected the bones. With the administration of painkillers and steroids, the patient is feeling better although he has does not have enough energy to ambulate well. From these conditions and age, the patient needs palliative care and processes such as surgery are not suitable. On dietary, the patient has no problem taking food and has been taking a lot of vegetables and other food to supplement his conditions. There is a need for the patient to improve energy levels to enable him to walk around and there is also the necessity of having food rich in iron and calcium. With the current medication and interventions, the patient is doing well although further diagnosis ought to be done concerning the cause of shortness in breathing.
Rick Maples has a wide range of conditions and there is a need for proper palliative care. Although the oxygen saturation level is okay, the cause of shortness of breath has not been established well. There is a need to do a chest x-ray or CT aortogram to establish well his conditions. This will determine if the patient has pleural effusion and whether it has to be drained. There is also a need for a dietary adjustment that can help stabilize his hypertensive conditions. Daily chest radiographs are also important since it helps evaluate the fluid status, also weight trend will evaluate the state of diuresis under various medication. Again, monitoring patient’s ambulation regarding length, distance, and usage of an assistive device are important. This will enable the medical practitioners to evaluate the functional status and patient’s activity. There is also the need for magnetic resonance imaging to establish the cause of difficulty in ambulation. During this session, the spinal cord will be examined closed and proper medications given.
MacGregor, G., & Kaplan, N. M. (2016). Hypertension. Abingdon: Health Press.
Mohrman, D. E., & Heller, L. J. (2018). Cardiovascular physiology. New York: McGraw Hill, Educational/Medical.
Vimalesvaran, K., & Marber, M. (2014). Myocardial Remodelling after Myocardial Infarction. Oxford Medicine Online. doi: 10.1093/med/9780199653461.003.0031