Clinically Significant Data for a 75-Year-Old Male Patient with Heart Failure and Diabetes, Exams of Nursing

Download Clinically Significant Data for a 75-Year-Old Male Patient with Heart Failure and Diabetes and more Exams Nursing in PDF only on Docsity! Heart Failure Home Health Reasoning 1 of 2 FIRST Home Health NurseVisit. Latest Update for Guaranteed Pass FrankSmith,75yearsold PrimaryConcept Perfusion InterrelatedConcepts(Inorderofemphasis) • ClinicalJudgment • PatientEducation • Communication • Collaboration NCLEXClientNeedCategories PercentageofItemsfromEach Category/Subcategory Coveredin CaseStudy SafeandEffectiveCareEnvironment ✓ ManagementofCare 17-23% ✓ ✓ SafetyandInfectionControl 9-15% HealthPromotionandMaintenance 6-12% ✓ PsychosocialIntegrity 6-12% ✓ PhysiologicalIntegrity ✓ BasicCareandComfort 6-12% ✓ ✓ PharmacologicalandParenteralTherapies 12-18% ✓ ✓ ReductionofRiskPotential 9-15% ✓ ✓ PhysiologicalAdaptation 11-17% ✓ InitialDatatoReviewfromChart: CurrentProblem/ReasonforHomeHealthCare: FrankSmithisa75-year-oldmalewhois5feet10inchestall(178cm).Hisbaselineweightis255lbs.(115.9kg-36.6 BMI).HehasahistoryoftypeIIdiabetes,myocardialinfarction,hypertensionandchronicsystolicheartfailure(ejectionfraction40%)s econdarytocoronary artery disease. Summaryof InpatientAdmission: Frankpresentedtotheemergencydepartmentcomplainingofweakness,fatigue,decreasedtolerancetoactivity,shortnessofbreathwit hexertion,weightgainofthree poundsin24 hours,andproductivecoughwithblood-tinged sputum. FurosemideIVwasadministeredtoaddress fluidvolumeexcessand4500mLfluidwasremoved.Beforedischarge,heisat hisbaselineweight.Reviewofmedicationandnutritiontherapywasprovidedbeforedischargeandhehadnoquestions. Re-Hospitalization RiskAssessment: This is Frank’s second inpatient admission in the last 30 days due to acute decompensated heart failure. He is dischargedwith a diagnosis of pulmonary edema and exacerbation of chronic systolic heart failure. A referral was ordered for homehealthcarefollow-up,andaregisterednurseisscheduledtovisithishomewithin24hoursafterdischarge toassesspatient, determinemedicationadherence,andhisunderstandingofmanagementofheartfailure. WhatdatafromthehistoriesareRELEVANTandmustbeinterpretedasclinicallysignificantbythenurse? (ReductionofRiskPotential) RELEVANTDatafromCurrentProblem: ClinicalSignificance: 75-year-oldmaleBMI36.6 TypeIIdiabetes,MI,HTN Chronicsystolicheartfailure(40%EF) Unhealthyweightcontributestodiabetesandheartdisease AllareunderlyingissuesthatcanleadtoheartfailureifnotmanagedLeft ventricle has become weak, not contracting properly, not able toforceblood out,only40%of totalblood RELEVANTData fromInpatientAdmission: ClinicalSignificance: Weak,fatigued,SOB,3lbweightgain,productiveco ughwith blood tingedsputum FurosemideIVadministered;4500mLremoved,at baselineweightbefore discharge Therapyprovided,noquestionsasked s/sofleftandright- sideheartfailure,basedonHxmostlikelyleftsideHF(indicatedbyrespirat orysymptoms)progressedintorightside HF (indicated by weight gain), productive cough with bloodpossibleindicatorofpulmonaryedema Loopdiureticforexcessfluidremoval,outcomeasexpectedwith4500mLrem oved andpt backatbaselineweight Educationisapriorityforthispt,needtoassesshisunderstandingof whatwastaughtevenifhehasnoquestions RELEVANTDatafromRe-Hosp. RiskAssess: ClinicalSignificance: secondadmissionin30days homehealthreferralordered Highriskforsameproblemtokeepreoccurring,educationispriorityCan assess pt at home, compliance with care plan, medicationadherence,andcaneducateandaddressanyareasofdeficit SocialHistory: Frankisaretiredengineerwhosewifediedunexpectedlyoneyearagoafterfiftyyearsofmarriage.Hehasbecomelessactivesinceshe diedandrarelygetsoutofthehouse.Sincehiswifedidmostofthecooking,Frankmostlyeatseither Patient lives alone; house is clean but somewhat cluttered.Patient states he avoidscooking, and takeout food containers are seen on top of the trash can. Medication bottlesare lined up on kitchen counter. He takes medications as prescribed, but thinks he hasforgottensomedosesfromtimetotime.Bringsoutabasket ofoldoutdatedmedicationshewill take if unable to pick up refill prescriptions on time. Patient states he has adequateinsurancecoverageforhisprescriptionsbutdoestrytostaggerrefillsduetoco-pays. cardiac rhythmPrevent potassiumdepletion fromloopdiuretics hyperkalemia,m onitor cardiacrhythm Digoxin:0.125mgPOd aily Digitalis glycosides Increase fore ofmyocardial contraction,decrease conductionthroughSAan dAVnodesHeart failure, atrialfibrillation increase cardiacoutputandde creaseHR Monitor apicalpulse for 1 minbeforeadmini stration(hold if <60),monitor for s/s oftoxicity(abdomi nal pain,N/V,bradyca rdia, visualchanges) MedicalManagement(includingPharmacologicandParenteralTherapies) HomeCareOrders: Rationale: ExpectedOutcome: InitiateHomeHealthCareServices Assessptunderstanding,educationonanyweakareas,helpimpr ovefunction. Preventfluidretention Preventexcessfluid,educateonhowtomonitor Assesssodiumandpotassium HomeHealth successful 2glowsodiumdiet Decreaseinfluidr etention, compliancewithdiet Fluidrestrictionof2000mLPOdai ly Decrease fluidretention Basicmetabolicpanel(BMP)o rderedin oneweek Levelswillremain WNL PartI:HomeAssessment: Asyouenterthehomeforthefirst time,thisiswhatyounotice: AssessPatientResponse: Describepatientresponseandanypotentialconcernsyouwantthenursetonoticeoriftheresponseisappropriate. Patientcommentsthathiswifepassedawayunexpectedlywithinthepastyear,hemissesher,and she took care of all the cooking and grocery shopping for them. States that he mostlyconsumes ready-to-eat meals now because they are handy and he couldn’t be bothered withspending a lot of time in the kitchen. He acknowledges less activity over the past year due toheart failure and feeling depressed. Reports he forgets to weigh himself on a regular scale asheisnot abletoseethe reading due toabdominal distension. Patientappearsopentohomecareservicesandskillednursingvisitsandasksappropriatequestions. WhatdatafromtheINITIALhomeassessmentandpatientresponseareRELEVANTandmustbeinterpretedasclinicallysignifi cantbythenurse?(Reduction of RiskPotential) RELEVANTDatafromHomeAssessment: ClinicalSignificance: Patientlivesalone,houseiscleanbutsomewhatcluttered. Patientstatesheavoidscooking,andtakeout food containers are seen ontop of the trash can. Medicationbottles are lined up onkitchencounter. Hetakesmedicationsasprescribedbut thinks he has forgotten somedoses fromtime totime. Brings out a basket of old outdatedmedicationshewilltakeifunabletopick up refill prescriptions on time,worriedabout co-pays Assess safety and fall risk, assess for any support, pt at risk fordepression,potentialisolation,pteducationpriority,assessADL’s Needdietmedication,educationptondietandrelationtohealthcare/ management,possiblecandidateformealsonwheels Assessmedicationroutineandhowtoimprove,suchasweeklyorganizer,ca lendartocrossoff,alarms/reminders Pt education priority, need to assess compliance with medications,remove and discard outdated medications, possible candidate forcopayassistance,discussinsuranceneeds,possiblecheaperversiono fmedications available? RELEVANTDatafromPatientResponse: ClinicalSignificance: Wife passed away unexpectedlywithin the past year, he misses her,and she took care ofall the cookingandgroceryshoppingforthem.Statesthathemostlyconsumesready-to-eatmeals now because they are handyand he couldn’t be bothered withspendingalotoftimeinthekitchen. He acknowledges less activity overthepastyearduetoheartfailureandfeelingdepressed. Reportsheforgetstoweighhimselfonaregularscaleasheisnotabletoseethereading due toabdominaldistension. Patientappearsopentohomecare Assessfordepression,assessdiet,pteducationpriority,mealonwheels/ senior centers Referral to mental health, dietician, and cardiac unit may benecessary,pteducationonmedicalcondition,diet,andexercise Pteducationpriority,riskforweightgainandsymptomexacerbation Goodsign,continuetoassessandmonitor,pteducationstillpriority,liste n to and address any concerns, utilize therapeuticcommunication Pteducation Assessvitals,lungsandheartM onitorweight Medication complianceDiet/nutriti on Exerciseprogram Assessunderstandingofcareplanandcurrenthealthcon cern,useteachbackmethod Monitorandassessfortrendssuchasweightgain,lungsoun ds,changesinheartsounds/rhythm HelpcontrolsymptomsandimprovethemDi etrestrictiontomanagefluidretention Improveactivityintoleranceandincreasestrength Pt willunderstandd isease and howtomanageit Ptwillremains table Decrease in fluidretention, BP willbestable,gluc osewill be controlledPt will be able toperform ADLsbetter, activitytolerance willimprove 3. Whatbodysystem(s)willyouassessmostthoroughlybasedontheprimary/priorityconcern?(ReductionofRiskPotential/ PhysiologicAdaptation) PRIORITYBodySystem: PRIORITYNursingAssessments: Cardiac Respiratory VitalsincludingHR,BP,lungsounds,andheartsoundsDail y weights to monitor for trends of weight gainEdemainlower extremitiesandabdominal Monitorintake/output Monitorlabvaluesforsodium,potassium,andglucoseAssessac tivity tolerance 4. Whatistheworstpossible/mostlikelycomplication(s)toanticipatebasedontheprimaryproblemofthispatient? (ReductionofRiskPotential/PhysiologicAdaptation) Worst Possible/Most LikelyComplicationtoAntic ipate: Fluidvolumeoverload NursingInterventionsto PREVENTthisComplication: AssessmentstoIdentifyProblem EARLY: NursingInterventionstoRescue: Pt education o importance ofsymptomsmanagementincludin gdiet and fluid restrictions andmedicationcompliance Trending assessment findingsincludingweight,HR,B P,lungsounds Weightgain(3lbsintwodays,5lbsinawee k) Increaseinedemainlowere xtremities/ abdomenIncreasein BP IncreaseofSOBatrestandwithactivityNo cturnaldyspnea ChangesinLOC Notify MD of changes, administeradditional furosemide and assess,monitorvitals,raiseHOBifapplic able,mayneedIVfurosemideifnochang es 5. Whatpsychosocial/holisticcarePRIORITIESneedtobeaddressedforthispatient? (PsychosocialIntegrity/Basic Careand Comfort) Psychosocial PRIORITIES: Emotionalsupport PRIORITYNursing Interventions: Rationale: ExpectedOutcome: Therapeuticcommunic ation, activelistening, asking openended questions, beingpresentandavaila ble Showscareandsupports,allowspatienttotalkopenlyandgiveexplanati ons, feelslistenedto Ptwillfeelheardandsu pported 6. Howwillthenurseassesswhatthispatientalreadyknowsabouttheirprimaryproblemandidentifyknowledgegaps? Askingopenendedquestion,havepatientteachbackwhattheknow,thenaddresswherethegapsare 7. What educational priorities will guide the development of a teaching plan for this patient and/or family? (HealthPromotionand Maintenance) EducationPRIORITY (Whatpatientneedstoknowtoprevent readmission): Self-management PRIORITYTopicstoTeach (Whattoolscanyouuseifavailable?): Rationale: Decrease in sodiumFluid restrictionMedication complianceDailyweight s Earlysignsofheartfailure/whentocallMD Prevent fluid retention, help manage andcontrolsymptomstopreventexacerbation s,monitorweightgain,willcall MDifweightgain more than 3lbs in two days, SOBincreases,becomes weakandfatigued PartIV:OngoingNursingPlanofCare Collaboration 8. Whatprofessionalreferrals(OT/PT,speechetc.)willbeneededtoadvancetheplanofcare? OT/PTforstrengtheningandabilitytoremainindependentathome,mentalhealthfordepression/griefcounseling,dietician/ nutritionformealplanning andassistance PlanningNextVisit 9. Whatdoesthenurseneedtoreinforce/ communicatebeforeleavingthisvisittoadvancetheplanofcareandensurepatientsafety inthehome? Reinforceteaching,dietchanges(consumelowsodiumfoods,restrictfluids),adheretomedicationsandtakeasprescribed,weighs elf dailyand keepalogto monitorforchanges, notify MDof anychanges