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Case Study: Nursing Process Treatment

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Jefferson College of Health Sciences - Pre-Licensure BSN
NURSING PROCESS APPLICATION
Client Initial __H____ No. of Days of Care ____2___________ Student ___Nicole Winfield________ Instructor ____Lyon______________

Brief Pathophysiology for Primary Diagnosis
Include signs & symptoms and treatment (including surgical procedures)

Patho: Pulmonary edema, fluid accumulates in alveoli and airways caused by fluid movement into the alveoli from the capillaries. Impairs lungs ability to oxygenate the blood. It is a life threatening symptom of acute heart failure syndrome.

Symptoms: Symptoms usually include dyspnea, rapid pulse, cool moist skin, cyanotic lips and nailbeds due to lower oxygen levels. Crackles can be audible in chest from …show more content…
Psychosocial Factors

Patient lives with daughter. States “I haven’t needed any help before this.”

Discharge Planning Needs / Community Resource Needs (What do you anticipate the patient needs)

Discharge to rehab facility. Nutrition consult.
Educational needs

Educate on low sodium diabetic diet. Medication teaching. How to accurately check blood sugar.

Diagnostic Data: Labs:

Lab Test Lab Date Lab Value Rationale for Abnormal/Significant labs

Troponin I Admission
Monday
Tuesday
Wednesday 0.34ng/ml Elevation of both Troponin and B Type Natriuretic peptide indicates continued ventricular strain which occurs with heart failure

Pro B Type Natriuretic peptide Admission
Monday
Tuesday
Wednesday 2701.0 …show more content…
5’7”____Wt. _202 lb_____ BMI____ Sex F Age 79 BS (0600) 85 BS(1120) 58 BS(1210) 97
Wed: BP _150/68_____P _60____ R _16____ T_96.8F_ BS 137 BP _153/68_____P _60____ R _18____ T__96.7F___
Functional Health Pattern (FHP): Health Perception-Health Management Needs: Met/Partially met/Not met Nutritional – Metabolic Pattern
Usual dietary habits, including food & fluid intake.

Breakfast: “ I usually eat frosted flakes with the berries in it and some coffee.”
Lunch: “ I usually eat a cucumber or tomato.”
Dinner: “I have fast food most of the time.”

“ I drink a lot of diet Coke. I don’t like milk but I put it in my cereal. I know eating all that fast food is probably what got in here in the first place.”

Admits she doesn’t follow a low sodium diet. General physical survey, exam of skin condition, skin turgor, mouth, and cranial nerves V, IX, X, XII. Address both nutrition and hydration status. Include upper GI assessment.

Patient appears well nourished. Skin is consistent with ethnicity, no lesions or rashes. Skin is moist, warm and elastic. Bottom dentures, partial top. Uvula is midline. Face is symmetrical with no droops or

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