Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol, coronary artery disease (CAD) and Diabetes Mellitus II. He has a 42-year history of smoking 1 pack of cigarettes per day, quit 3 years ago. He is a retired truck driver who lives in a retirement community. He was brought into the emergency department (ED) by a friend after complaining of a massive headache, 10 out of 10, which felt like a “tight headband” around his head.
Mr. Johnson stated that his pain had increased as the day progressed. Vital signs upon intake revealed the following: 188/104, 108 BPM, 22 RR, 93%, 99.2F, when questioning the patient about the events leading up to this morning, he stated that he did not take his “water pill” or medications that his doctor prescribed. He added that he stopped the water pill because he keeps going to the bathroom, and is unable to sleep at night. He states he is on several heart medications. He did not bring any of his medication with him to the emergency department ED.
Physician’s orders included:
Questions:
Interventions
1.Abnormal assessment findings are vital signs.Hypertension, tachycardia and low saturation level.
2. Headache related to physiological changes in the body as evidenced by pain scale score.
Tachycardia related to pain as evidenced by checking pulse rate 108.
3.Risk for decreased cardiac output related increased blood pressure.
4.EKG shows sinus tachycardia.
CT shows normal study.
5.Goals are to reduce pain .It is the need of the patient.Hence it is patient centered goal.
6. Advice to have diversion like music therapy.
Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol,...
Melissa White is a 67-year-old female with ischemic cardiomyopathy and a history of chronic heart failure, HTN, high cholesterol and coronary artery disease (CAD). She is a past smoker that quit 5 years ago after her husband died of emphysema in 2007. She is a retired school teacher who cares for her ailing 90-year-old mother at home. Her neighbor brought her to an emergency department because she was complaining of shortness or breath, fatigue and swelling in her ankles and...
Respiratory Assignment This patient is a 75 year old male with a history of emphysema, coronary artery disease and benign prostatic hypertrophy. His BPH was treated with a TURP three years ago. He had a triple CABG two years ago. Patient reports smoking 2 packs per day until 2 years ago. He has been oxygen dependent for the last two months. He was admitted for an episode of vertigo which caused him to fall. His son brought him to the...
Why did Mr. Stone develop heart failure? The patient is a 60-year-old male who has hypertension and heart failure. He had Hydrochlorothiazide prescribed by MD for his hypertension a couple of years ago. However, the patient has not taken the medications as directed. He complains that he is experiencing increasing fatigue, shortness of breath, paroxysmal nocturnal dyspnea and weight gain. An ECG and a chest x-ray were performed and also had blood drawn. The patient is alert and oriented. His...
Respiratory Assignment This patient is a 75 year old male with a history of emphysema, coronary artery disease and benign prostatic hypertrophy. His BPH was treated with a TURP three years ago. He had a triple CABG two years ago. Patient reports smoking 2 packs per day until 2 years ago. He has been oxygen dependent for the last two months. He was admitted for an episode of vertigo which caused him to fall. His son brought him to the...
K.B. is a 21-year-old man with a past medical history (PMH) of seizure disorder controlled with carbamazepine (Tegretol). He was accidentally struck in the head by a pitched baseball while batting in a baseball game. He was unconscious for about 5 seconds, then awakened and was alert and responsive. After a few hours, K.B. returned home with complaints of a "splitting" headache, drowsiness, slight confusion, and some nausea. K.B. was taken to the local hospital emergency department (ED), where a...
History of Present Problem: E.W., a 76-year-old white man, comes to the emergency department after a syncopal episode and complaint of mild chest discomfort at a local restaurant. He is accompanied by two friends. Subjective Data • Has been feeling weak for a few days • Became dizzy and fainted while awaiting his dinner • Takes one medication, a “water pill” for high blood pressure 1. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? 2. How can...
A 50 year old male patient presented to the emergency department at 2AM with vomiting and abdominal pain. He had a 2 week history of polyuria and polydipsia, accompanied by a 20 pound weight loss and blurred vision. His medical history was unremarkable, except for being treated with hypertension with lisinopril 40 mg daily, which provided good control. His blood pressure on admission was 135/80. He is a smoker and smokes ½ pack of cigarettes per day. Results of hospital...
A 50-year-old male patient presented to the emergency department at 2 AM with vomiting and abdominal pain. He had a 2-week history of polyuria and polydipsia, accompanied by a 20-pound weight loss and blurred vision. His medical history was unremarkable, except for being treated for hypertension with amlodipine 10 mg daily, which provided good control. Results of hospital laboratory studies revealed that the patient's initial blood glucose level was 1192 mg/dL. VS 97.0 HR98, B/P 168/98 Resp 20. O2stat 95%...
An 80 year-old male was transported by ambulance to the emergency department (ED) for evaluation after experiencing an unwitnessed fall in a local nursing home. The patient resided at the nursing home and had a medical history of severe dementia and osteoporosis. Upon arrival to the ED, the patient was triaged by nursing staff. The triage documentation noted the patient’s vital signs were stable, that he was a poor historian and complained of “hurting all over”. After triage was completed,...
Case Study #2 Pharmacology Nursing Process G.M. is a 50 year-old Caucasian male who presented to the emergency department with chest pain, after playing basketball with his son. He had no significant medical history before the event and was diagnosis with a myocardial infarction. He responded well to medical management and is set to be discharged today. Your assessment notes the following: • Vital signs BP 100/65, heart rate 72 bpm, respirations 28 bpm, and temperature 98.9°F. • Normal S1...