Question

Charles is a 60-year-old male who was discharged from hospital 3 days ago for an acute flare-up of his chronic condition. It is 8:30 pm and he is calling nurse triage with increased dyspnea and orthopnea. He says he hasn’t done anything different since being discharged but is still feeling very tired all day- “more than usual”.   He says his shortness of breath is worse when lying flat, so he slept in his recliner last night. Charles says he has some swelling around both ankles that is new today.   He also tells the nurse that he has gained 5 pounds since yesterday morning.   Charles is A&O x 3.

Past Medical History: The nurse is able to ascertain that Charles had been smoking 1 pack of cigarettes a day for 20 years but quit almost 5 years ago. He rarely drinks alcohol and does not use street drugs. Charles is a supervisor at a warehouse which he tells the nurse involves some walking but most of his day is sitting behind a desk or at a work site.   He lives with his wife of 40 years and has 3 grown children, all of whom are very involved and supportive to their parents. In addition to the chronic condition he is calling for tonight, Charles has a history of high blood pressure, hyperlipidemia and had a heart attack 5 years ago.

Medications: Daily medications for Charles include Lasix (diuretic), Vasotec (ACE Inhibitor), and Toprol (Beta-blocker).

Additional Information: Charles tells the nurse he has been talking with a Disease Case Manager for the last 2 years to help him manage his condition. She recommended a salt-restricted diet, restricting his fluid intake, checking his weight every day and mentioned talking to his doctor about starting a walking regime each day.

Questions

1. What questions might you ask Charles?
2. What assessment data is important?
3. What assessments would you perform?
4. What are your nursing diagnosis for this patient?
5. What goals would you have for his care?
6. What interventions will you do for this patient?
7. Please provide the education of health promotion and disease prevention that you will give this patient.

Answer 1

●Some of the questions which can be asked to the patient are

• Duration of pain
• Relief measures taken in home
• Medication adherence
• Any specific symptoms

●The assessment which has to be done are

• Any complaints of cough (can happen because of beta blocker,one of the sign of right side heart failure)
• Asking the fluid intake and the urine output because any problems in the filtration can contribute to fluid retention
• Any complaints of pain at chest ,dizziness to rule out heart attack
• Dietary intake, life style can be a factor for cardiovascular
• Vital signs

●The assessment which has to be performed are

• Vital signs monitoring
• Intake and output measurement
• Weight monitoring and recording
• Auscultation to find out any abnormal heart sounds ,lung sounds
• Physical examination to assess any any bodily changes

●The nursing diagnosis for this patient

• Fluid volume excess related to altered cardiac function as evidenced by swelling in the ankles
• Impaired tissue perfusion related to decreased cardiac function evidenced by difficulty in breathing, orthopnea
• Impaired sleep pattern related to decreased lung function as evidenced by sleeping posture,dyspnea

●The goals for this patient are

• To reduce the edema and decrease body weight
• To maintain normal breathing pattern ,difficulty in breathing
• Prevention of complications

●The intervention required for this patient are

• Monitoring vital signs,as or can provide basic details of bodily changes
• Administration of medication
• Administer oxygen to relie e breathing difficulties
• Ensure Fowler's position to improve lung capacity
• Reach breathing exercises to improve lung function

●The health education which can be done are

• Medication adherence
• Simple daily exercise as per advice
• Report immediately in case of any adverse events
• Low salt ,low fat ,fluid restricted diet
• Avoid any passive smoking
• Avoid stress
• Inculcate yoga ,meditation to improve overall health