Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian m
Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male… Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II diabetes. ?Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because he had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with increased difficulty breathing when he woke up and his wife called 911. ?Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat. He was placed on oxygen by facemask and albuterol nebulizer administered with some improvement in his breathing. ?His RR is now 24 upon arrival to the emergency department ED). His initial labs have resulted; creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7) and BNP 944 (last adm. 322). Jerry is given furosemide 40 mg IV in the ED and had 800 mL urine output in the last hour. He is admitted to cardiac telemetry, and you are the nurse responsible for his care. Relationship of PMH & Current MedsPast Medical History (PMH):Home Medications:HyperlipidemiaHypothyroidismType II diabetesDiastolic heart failureChronic kidney disease stage IIIFurosemide 20 mg PO every morningAtorvastatin 40 mg PO at bedtimeMetoprolol 50 mg PO BIDLevothyroxine 112 mcg PO dailyExenatide microspheres 2 mg subq. weeklyVital SignsCurrent VS: Most Recent in ED: P-Q-R-S-T Pain Assessment:T: 98.2 F/36.8 C (oral) T: 98.8 F/37.1 C (oral) Provoking/Palliative:P: 88 (reg) P: 92 (reg) Quality: DeniesR: 24 (reg) R: 24 (reg) Region/Radiation:BP: 142/76 BP: 148/80 Severity: O2 sat: 93% 4 liters n/cO2 sat: 94% 4 liters n/cTiming: Nursing AssessmentCurrent Assessment:GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably.NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist.RESPIRATORY: Breath sounds coarse crackles in bases bilat.with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort.CARDIAC: Pale/pink, warm & dry, 2+ pitting edema in feet and ankles, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. Unable to assess JVD due to obesity/thick neck ABDOMEN: Abdomen round, soft, and nontender. BS + in all four quadrantsGU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.Put it All Together!Problem: Pathophysiology of Problem in OWN Words:Primary Concept(s):. Nursing Plan of CareWhat nursing priority (ies) will guide your plan of care? Nursing PRIORITY: PRIORITY Nursing Interventions:Rationale: (include reference) Expected Outcome: Medical ManagementCare Provider Orders: Mechanism of Action: Expected Outcome:Administer the following home medications: Atorvastatin 40 mg PO dailyMetoprolol 50 mg PO BIDLevothyroxine 112 mcg PO dailyNew order: Heparin 5000 units subq. BID Medication Administration? Identify the "rights" of safe medication administration?? Identify essential steps the nurse must implement to safely administer ORAL medications in practice?? What essential teaching will the nurse reinforce about these medications? ? Atorvastatin 40 mg PO daily? Metoprolol 50 mg PO BID? Levothyroxine 112 mcg PO daily? New order: Heparin 5000 units subq. BID Evaluation: Two hours later...? Jerry's respiratory rate has increased to 28 and his O2 sat has dropped to 88-90% on 4 liters n/c. ? Coarse crackles are present halfway up bilaterally. He states he has a hard time catching his breath at rest. Status Improved?Evaluation of Current Status: Modifications to Current Plan of Care:Care Provider Orders: Rationale/Mechanism of Action: Expected Outcome:Furosemide 40 mg IV BIDPlace on high flow n/c if unable to maintain O2 sat >92% on 6 liters n/c Evaluation of IV Site? When assessing the peripheral IV site, you notice that the site appears moist, cool to the touch with fluid leaking at the insertion site when flushed with saline.? The extension tubing is dangling with one piece of tape holding it to the patient is beginning to peel off.Parenteral Med Administration? 1. Identify the essential steps the nurse must implement to safely administer subcutaneous medications? ? 2. Recognizing that the IV has infiltrated, identify the essential steps that the nurse must implement to start an IV?? 3. Identify the essential steps the nurse must implement to safely administer intravenous medications? Patient TeachingMedications: Patient Education:Furosemide 40 mg IV BID Reflect: What Did You Learn?What Did You Learn? What did you do well in this case study?What could have been done better?What is your plan to make any weakness a future strength? Health Science Science Nursing NUR 112
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