Assignment task:
Nursing Report 0845: C. Jones is a 68-year-old male with a history of congestive heart failure (CHF) who presented to the ED 2 days ago with shortness of breath, fatigue, weight gain, and ankle edema. An echocardiogram upon admission showed an ejection fraction (EF) of 35%. The chest x-ray revealed bilateral congestion in the lower lungs. Mr. Jones was admitted to the medical unit 2 days ago. Despite IV Lasix, resulting in a weight loss of 4 lbs., he remains short of breath and requires O2 2 LPM on the nasal cannula to maintain a saturation > 92%. He complains of lightheadedness when standing and has required assistance when out of bed.
History of Present Illness: C. Jones presented to the Emergency Department 2 days ago with dyspnea, orthopnea, fatigue, a weight gain of 10 pounds, and ankle edema. His appetite is poor; he complains of slight nausea but no emesis. The patient has received IV Lasix twice daily and has diuresed approximately 2 L (weight loss of 4 lbs.). His last lung assessment revealed breath sounds, including fine crackles in the bases bilaterally, no cough, and 3+ edema in the lower extremities.
PMH: hypertension (10 years), atrial fibrillation (5 years), congestive heart failure (5 years), hyperlipidemia.
PSH: Denies
Allergies: NKDA
Family History: unknown
Social History: C. Jones lives with a wife, and they both retired three years ago. He worked as a school maintenance supervisor. C. Jones has three adult children, who are very supportive of their parents. He is a Baptist. C. Jones smoked one pack of cigarettes per day for 20 years but quit smoking two years ago. C. Jones is a social drinker.
Case Scenario Assignment: Reflection Provide the answers to the following questions. You must type directly into this form. Handwritten form will not be accepted. Complete and document as you would in the hospital setting; avoiding patient identifiers and slang, using correct spelling and grammar, providing accurate data from scenario and patient chart. This is a critical thinking reflection of the completed case scenario. See rubric for grading of the assessment form and reflection.
1. What is the medical diagnosis for this patient? Provide the pathophysiology for this diagnosis. Include a reference AND in-text citation. Must be in APA format.
2. Identify two or more common assessment findings for any patient with this condition.
3. Identify two or more findings that you noted in the scenario that helped you recognize if your patient was improving or deteriorating.
4. Identify all abnormal laboratory and diagnostic data for this patient. Include the test name, patient result and if the result was high or low (for laboratory data).
5. What assessment findings might you expect to find in a patient with each of those abnormal laboratory or diagnostic values? Include information for each identified abnormal laboratory or diagnostic test. For example: "I| would expect my patient with a positive urine culture to have cloudy and malodorous urine, dark colored urine, bladder pain, urinary frequency, etc."
6. Identify two nursing diagnoses AND identify which one is the priority. Why did you choose these two diagnoses? Use Lippincott Advisor Problem Based List.
7. What are possible NURSING interventions you might implement for this patient? Include an assessment-based intervention, an action/do intervention, and a monitoring intervention.
8. Identify a medication that may be needed for this patient related to the priority nursing diagnosis you identified above. Include the name of the medication, indication and possible side-effects you will monitor for.
9. What additional information would you like to know or assess to better care for this patient and why? Include at least two points.