Medical Surgical

Explore in” rel=”nofollow”>in detail, two of the actual or potential patient problems identified in” rel=”nofollow”>in assessment 1

review the patient care plan submitted in” rel=”nofollow”>in assessment 1 and select two of the identified patient problems (Impaired gas exchange related to bilateral crackles in” rel=”nofollow”>in the lungs as manifested by shortness of breath, Activity in” rel=”nofollow”>intolerance related to impaired gas exchange as evidenced by difficulty of breathin” rel=”nofollow”>ing). For these two problems students are to provide an evidence based plan of care.

Patient Background:
Day 1 of admission
Mr Peter Lars is a 62 year old male who presented to the Hospital Emergency Department with chest pain” rel=”nofollow”>in and shortness of breath. Mr Lars was brought in” rel=”nofollow”>in by his wife and was triaged at 1000hrs. He stated that he was runnin” rel=”nofollow”>ing late for work and was racin” rel=”nofollow”>ing to get himself ready, when he experienced the onset of these symptoms. He tried to contin” rel=”nofollow”>inue to get himself to work, however the symptoms contin” rel=”nofollow”>inued for over an hour and his wife in” rel=”nofollow”>insisted he go to hospital.
Mr Lars has an extensive medical history. He was diagnosed with and commenced treatment for type 2 diabetes 16 years ago, which has been managed with oral medications. Mr Lars has established peripheral vascular disease (PVD) and symptomatic neuropathy, both complications of his diabetes. Other medical history in” rel=”nofollow”>includes angin” rel=”nofollow”>ina, hypertension and dyslipidaemia, which are generally well controlled with antihypertensive and hypolipidaemic agents.
Mr Lars is an ex-smoker and non-drin” rel=”nofollow”>inker, and has no known allergies. He had an Acute Myocardial Infarction (AMI) in” rel=”nofollow”>in 2010 for which he had a coronary angioplasty and stents. Mr Lars is currently under the care of a cardiologist, Dr Blair.
Mr Lars is also very anxious about the fact that he is havin” rel=”nofollow”>ing more time off work. His wife has stated that she fears if he has another hospital admission, his employer will ask him to retire. She says this is placin” rel=”nofollow”>ing a lot of stress on Peter and she has noticed a recent declin” rel=”nofollow”>ine with his health over the past 4-5 months. Mr and Mrs Lars have three adult children, who all live in” rel=”nofollow”>in the Sydney Metropolitan area and see them regularly.

Admission Data (ED):
The condition of Mr Lars on admission in” rel=”nofollow”>included the followin” rel=”nofollow”>ing:
HR 125 BPM (sin” rel=”nofollow”>inus tachycardia)
BP Sittin” rel=”nofollow”>ing: 126/68 standin” rel=”nofollow”>ing: 118/58
Resps. 28 BPM non-productive cough; pt. speakin” rel=”nofollow”>ing in” rel=”nofollow”>in in” rel=”nofollow”>incomplete sentences
O2 Sats. 91% RA this in” rel=”nofollow”>increased to 95% with O2 6L/min” rel=”nofollow”>in via the NRB
Temp. 36.5oC
LOC Alert and orientated to person slightly confused with time and place GCS 14/15; complain” rel=”nofollow”>ins of feelin” rel=”nofollow”>ing light headed when gettin” rel=”nofollow”>ing up quickly.
Pupils Equal and reactive to light
Pain” rel=”nofollow”>in 4/10 focused left upper chest area – reduced with O2 admin” rel=”nofollow”>inistration
Airway Patent
In emergency oxygen therapy was contin” rel=”nofollow”>inued. A comprehensive respiratory assessment showed that Mr. Lars had coarse crackles bilaterally in” rel=”nofollow”>in the bases of his lungs. It was also noted that Mr. Lars had oedema in” rel=”nofollow”>in both ankles. An IDC with hourly urin” rel=”nofollow”>ine measure bag was in” rel=”nofollow”>inserted and IV Lasix was given. After the admin” rel=”nofollow”>inistration of the Lasix, 200mls of urin” rel=”nofollow”>ine was drain” rel=”nofollow”>ined via the IDC. BiPAP was considered, however Mr. Lars was found to be improvin” rel=”nofollow”>ing and therefore was contin” rel=”nofollow”>inued on oxygen therapy (O2 6L/min” rel=”nofollow”>in via NRB). Decision made to admit and he has been scheduled for an echocardiogram later today.

Handover Emergency Department to Ward 1A:
This is Mr Peter Lars, a 62 year old male who was brought in” rel=”nofollow”>into Hospital ED by his wife after experiencin” rel=”nofollow”>ing SOB and chest pain” rel=”nofollow”>ins at home this mornin” rel=”nofollow”>ing. On arrival he was tachycardic, however in” rel=”nofollow”>in sin” rel=”nofollow”>inus rhythm. He was still experiencin” rel=”nofollow”>ing SOB and was only able to speak in” rel=”nofollow”>in in” rel=”nofollow”>incomplete sentences. Further assessment revealed bilateral crackles in” rel=”nofollow”>in the lung bases and oedema in” rel=”nofollow”>in both ankles. We commenced O2 therapy via the NRB, admin” rel=”nofollow”>inistered IV Frusemide and in” rel=”nofollow”>inserted an IDC with hourly urin” rel=”nofollow”>ine measure bag. The IDC has drain” rel=”nofollow”>ined 400mls of clear urin” rel=”nofollow”>ine so far. Mr Lars is now reportin” rel=”nofollow”>ing to be more comfortable. His chest pain” rel=”nofollow”>in has subsided and his WOB has reduced. He has a provisional diagnosis of CCF and is for an echo later today. Under the care of Dr Giles

Condition on Arrival to the ward:
HR 100 BPM (NSR)
BP Sittin” rel=”nofollow”>ing: 130/70 standin” rel=”nofollow”>ing: 120/60
Resps. 22 BPM non-productive cough;
O2 Sats. 96% with O2 6L/min” rel=”nofollow”>in via the NRB (drops rapidly to 88% on air)
Temp. 36.5oC
LOC Alert and orientated GCS 15/15; complain” rel=”nofollow”>ins of feelin” rel=”nofollow”>ing light headed when gettin” rel=”nofollow”>ing up quickly.
Pupils Equal and reactive to light
Pain” rel=”nofollow”>in 1/10 focused left upper chest area – reduced with O2 admin” rel=”nofollow”>inistration
Airway Patent
Lungs Bilateral Coarse Crackles

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