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Presentation/PPT
27/08/2022
Question:
Clinical scenario:
heart failure – ISBAR
Identification
Mrs. Johnson is a 62-year-old female who presented to the ED at 7am today.
Situation
She was c/o headaches, dizziness, fatigue, visual disturbances, and palpations. She also describes feeling SOB on mild exertion.
Background
History:
Ax: NKA
Meds: candesartan 8mg Mane, metformin SR 1000mg mane
Past illnesses: hypercholesterolemia, T2DM, Increased BMI 30
Last meal: 7pm (dinner last night), chicken parmigiana with chips at the Kenilworth Hotel.
Events leading up to presentation:
The patient had started walking the dog, then became breathless shortly after leaving home. Mrs. Johnson has recently moved to a hobby farm near Kenilworth, after the death of Mr. Johnson. Mrs. Johnson has not met the local GP yet. The patient does not drive and relies on her Son, Derek for transport (Derek lives in Caloundra). The patient has no recollection of being diagnosed with a cardiac arrhythmia.
Assessment
Primary survey:
airway is clear,
breathing – crackles on lung auscultation, slight cyanosis
circulation sluggish capillary refill, cold peripheries, irregular pulse
disability alert, oriented, with some visual disturbances
exposure peripheral oedema
Secondary survey:
Full set of vital signs: Temp 37, GCS 15, HR 110 (irregular), BP- 165/100, Sp02- 89% on Room Air, RR 24. BGL: 11mmol
Recommendations
She was given her regular medications and commenced on metoprolol 50 mg mane, PIVC in situ R) ACF- patent.
Answer the following questions for your selected case
Question 1:
Identify 2 priority problems for your patient. Refer to the ABCDE framework to justify your decision andwith an adequate justification
Two priority problems for the patient are.1
st
is impaired gas exchange and 2
nd
is impaired circulation. Please only use these two priorities because it is confirmed from teacher
Question 2:
Explain how these problems developed and their clinical manifestations (signs and symptoms) from the case using your knowledge of pathophysiology.Adequate discussion of the pathophysiology in relation to the assessment data and identified priority problems.
Question 3:
Identify 2 interventions (one for each priority problem). Provide a rationale for each intervention that refers to pathophysiology, as well as a discussion of related nursing care. Accurate discussion of the role of the registered nurse in implementing and evaluating interventions for the patient with health alterations in the scenario.
Question 4:
Outline and discuss appropriate discharge planning for this patient that is guided by the social justice framework.The discharge plan demonstrates knowledge of actions the registered nurse may take to encourage access to and participation in healthcare and justifies these actions through the application of the social justice framework.
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