Question

Write a nurses note on a 75yr-old single mother who was brought in the ER due to high blood pressure, Hypertension and Congestive heart failure. What the cause and and positive treatment. Write nursing diagnose and possible nursing intervention. Use this picture below as a guide line in passing d patients.

REGIONAL WRITE-UP GENERAL SURVEY, VITAL SIGNS Date Examiner AgeGender Patient Occupation I. Physical Examination A. General survey 1. Physical appearance Gender Level of consciousness Skin color Facial features 2. Body structure Stature Nutrition Symmetry Posture Position Body build, contour Any physical deformity 3. Mobility Gait Range of motion 4. Behavior Facial expression Mood and affect Speech Dress Personal hygiene B. Measurement 1. Height:cm; 2. Weight: ft/inches 3. Body mass index lb kg: 4. Waist circumference inches C. Vital signs 1. Temperature 2. Pulse rate Rhythm Force 3. Respirations 4. Blood pressure: arm; L arm II. Summary Write a summary of the general survey, including height, weight, and vital signs. This will serve as an introduction for the complete physical examination write-up.

Answer 1

Examiners Dr george Female occupaticn louse wite 1 PHYSICAL EXAMINATION: Genesal surgery prsical oppraiane : pakent leekeing dall, por kgienia paird espreters oppeaante a Genderferale evel of consciousness : constau ,07, erted totimerplce skin color white Fautal featuwer paiofl expression Score 110 Smmety ymnefrical posture Gcod Bedy huld, erken: hn hdy built dry deformiy NO Signis cant histos Rarge of mottn: timited, all parge of motepe parita. 4 Be haviocr expventr: painhl tautal expne tione

Speech : able to peak Roess ; cAble -to Dress ξ under on her coon. personal hygfere poor pesonal hygiene B. Measurement Height 。 weght : 65 kgs 3 BH 5. y waist circumkrene : &o cm C. vital srons Temperature : Qe 6 2.pculse vate 120 mi 3.Rhythmrreqular 4 Force High 5Respiration 26 mi 6. Blood pressure: 150-mmti ) Aghtom, luo ,left on. letft arm 70 summany h year old sinale mother Came to the On phiygical eominaton: pahent hauing 8p Since is year attock 2 tnmes tn and cardeoc attack a heart post yearg. 冰 cAAkv Examinatfoの, we found that ehe kroon case of hyper tension and congestve heart fathire.

Cause :

There are many risk factors For congestive heart failure includes :

• Coronary heart diseases
• High BP
• Disorders of heart valves.
• Positive family history .
• Increased cholesterol levels
• Obesity
• Physical inactivity.
• Diabetes
• Smoking etc .

For this patient cause is high Bp .

Treatment :

• Treatment based on severity .
• Treatment can include eating less salt , limiting fluid intake and taking prescription medication .in some cases a defibrillator or pacemaker implanted .
• Self care : physical excercise ,quiting smoking , weight loss and low sodium they .
• Medications : diuretic, betablockers ,ACE inhibitors , anti hypertensives drugs ,dietary supplement , blood pressure support ,vaso dialators and heart medication .
• Medical procedures : cardiac resynchronisation therapy
• Surgery : CABG

Nursing diagnosis :

• Acute pain related to decreased myocardial oxygen supply .
• Impaired gas exchange related to ventilation perfusion imbalance .
• Decreased cardiac output related to altered contractility ,preload and afterload .
• Activity intolerence related to imbalance between 02 supply and demand
• Knwoledge deficit related to medications
• Anxiety related to present status ,pain ,perceived threat of death.

Nursing interventions :

• Rapid triage to appropriate environment For safe clinical care : coronary care unit , cardiology ward, general medicine ward
• Objective monitoring For change in signs and symptoms suggestive of response to treatment .
• Promptly identify and address relevant changes in clinical status.
• Discharge planning and referral to multidisciplinary disease management programme.
• Anxiety of patient should addressed by promptly answering questions and providing clear information to the patient and family .
• Ensure effective and consistent communication between the patient and family and multidisciplinary team .