Question

Case Study Mr. Grinch is a 68 year old male who presented to the Emergency Department...

Case Study Mr. Grinch is a 68 year old male who presented to the Emergency Department (ED) with severe shortness of breath (SOB), fatigue, and recent weight gain of 5 kg. It is two days after Thanksgiving and Mr. Grinch has been eating salted ham and a large amount of leftovers for every meal. He is having trouble speaking, but reports he has been having difficulty sleeping and states, “I feel like I’m drowning. I’ve tried using multiple pillows to get rid of this feeling, but the only way for me not to feel so SOB is if I sleep sitting up”. This is Mr. Grinch’s second admission this year for a similar complaint. He has a history of heart failure, Ischemic heart diseases [with his last echo showing an EF 25%], hyperlipidemia, Coronary Artery Disease (CAD) [CABG 2 vessel 2 years prior], hypertension (HTN), and Type II diabetes. The patient’s son, who is also his main caregiver and lives nearby, has accompanied him to the ED and reports that Mr. Grinch is not adherent to either diet nor medication regimens. He also reports that Mr. Grinch likes to eat fast food or frozen dinners for most of his meals a week. He refuses to exercises and generally lives a sedentary lifestyle. Home meds include Lisinopril 5mg, Metoprolol 25mg, Spironolactone 25mg, Atorvastatin 10mg Daily. Assessment in the ED revealed: vitals BP: 198/103, HR 131, RR 22, T 98.4, O2 of 84% on Room Air so the patient is placed on 10L Non rebreather which increases O2 to 94%. The patient is alert, oriented x4, anxious, PERRLA, with facial symmetry and reflexes intact. The EKG shows sinus tachycardia and no new ischemic changes. Cardiac assessment revealed s3, bilateral pitting pedal edema 2+, and 2+ pulses in all extremities. Auscultation of the lungs revealed bibasilar pulmonary rales. There is also use of accessory muscles, nasal flaring, and severe SOB. The abdomen was distended/non tender with positive hepatojugular reflux. All other assessment findings were normal. In addition to the EKG, a chest x-ray was performed and showed cardiomegaly, vascular engorgement, and mild interstitial edema. Labs: Na 128 mEq/L, K 5.2 mEq/L, BUN 82 g/dL, Crt 1.8 mg/dL, trop I 0.1 ng/mL , BNP 1300 pg/mL, Glu 140 g/dL. Mr. Grinch receives oxygen by non rebreather mask, is placed on fluid restriction and strict I&O. Therefore, it’s imperative that an indwelling foley catheter is inserted. Orders are made for Furosemide 40 mg IV and Nitroprusside 0.3mcg/kg/min IV. Upon reassessment in 30 mins, Mr. Grinch reports a decrease in SOB and has put out 500 mls of urine. Lung auscultation shows improved, but still present rales. Vitals are now BP 150/96, HR 89, RR18, T 98.5, and O2 of 97% on 10L non rebreather. Mr. Grinch is stable and is now being transferred to a telemetry floor for further monitoring. When setting patient goals for Mr. Grinch, the nurse decides the priorities for the patient will be to improve ventilation, maintain hemodynamic stability, and be able to verbalize understanding of his condition and associated treatments prior to discharge. Case management will be consulted as the patient lives alone and may require home health care upon discharge.Neuro: What objective findings upon arrival to the ED could suggest an altered LOC? How would we best identify Mr. Grinch’s LOC on exam? Pulm: What potential respiratory process is occurring given Mr. Grinch’s clinical presentation? FEN: How can we best define the fluid volume status of Mr. Grinch? Nursing Diagnosis What nursing diagnosis would be most appropriate? (give one priority).

Homework Answers

Answer #1

1. Objective findings of altered LOC:

Orientation, verbal response and PERRLA should be assessed. As Mr.Grinch had not slept well since two days his sleep and mental ability could have been altered. Continuous GCS monitor will be helpful to find out early symptoms of altered LOC.

2. PULM:

As per his clinical presentation, he has orthopnea and Hus health history also relates that he could suffer with Pulmonary edema. Pulmonary edema is a major complication of heart failure.

3. FEN:

Fluid is retented in Hus body as evidenced by weight gain, shortness of breath and orthopnea. Strict I/O should be maintained.

Nursing diagnosis:

Impaired gas exchange related to pulmonary edema(fluid retention in the lungs) as evidenced by rale sound.

Know the answer?
Your Answer:

Post as a guest

Your Name:

What's your source?

Earn Coins

Coins can be redeemed for fabulous gifts.

Not the answer you're looking for?
Ask your own homework help question
Similar Questions
Mr. Grinch is a 68 year old male who presented to the Emergency Department (ED) with...
Mr. Grinch is a 68 year old male who presented to the Emergency Department (ED) with severe shortness of breath (SOB), fatigue, and recent weight gain of 5 kg. It is two days after Thanksgiving and Mr. Grinch has been eating salted ham and a large amount of leftovers for every meal. He is having trouble speaking, but reports he has been having difficulty sleeping and states, “I feel like I’m drowning. I’ve tried using multiple pillows to get rid...
Mr. McClaren is a 48-year-old man who is admitted to the emergency department (ED) with abdominal...
Mr. McClaren is a 48-year-old man who is admitted to the emergency department (ED) with abdominal pain and general weakness. He reports that he drinks “one bottle of scotch whisky every week for the past one year, and one to two cans of beer during the weekends.” For the past three months, his condition has started to deteriorate. His wife claims that “he has not been eating well for the past three months”. Mr. McClaren reports he has passed dark...
Mr J, a 53 year old white male presents to the Emergency Dept (ED) for his...
Mr J, a 53 year old white male presents to the Emergency Dept (ED) for his third visit in a 3-month period with a chief complaint of epigastric pain. The patient states that he first came to the ED 3 months ago with the complaint, states that his symptoms weren't that bothersome then but had been present for a couple months, he couldn't get a same-day appointment with his primary care provider (PCP), and the receptionist at the PCP's office...
Case Study The patient is a 41-year-old male who has a longstanding history of hypertension and...
Case Study The patient is a 41-year-old male who has a longstanding history of hypertension and diabetes and presents with a complaint of pruritis, lethargy, lower extremity edema, nausea, and emesis. He denies any other medical illnesses. On physical assessment, the patient is a well-developed, well-nourished male in moderate distress. Blood pressure 180/110, pulse 80, respirations 24 and he was afebrile. Bodyweight 76.5 kg. HEENT was remarkable for fundoscopic findings of A-V nicking and copper wire changes consistent with the...
case study Ahmad is a 74 year old male patient who has been admitted to the...
case study Ahmad is a 74 year old male patient who has been admitted to the medical ward with acute fatigue, severe shortness, orthopnea and productive cough with hemoptysis. Ahmad's health conditions started to deteriorate since he had an acute myocardial infarction (MI) five years ago. He also presented with lower limbs edema including ankles and feet. According to Ahmad, the edema has started about 1 year since he had the MI. Ahmad also has a history of hypertension and...
Brief Patient History Mr. A is a 58-year-old Japanese-American admitted to the unit from the emergency...
Brief Patient History Mr. A is a 58-year-old Japanese-American admitted to the unit from the emergency department with complaints of paresthesias, lower extremity weakness (onset 2 days ago), and difficulty walking today. Mr. A reports to being in “good health” except for having the flu 3 weeks ago. Mr. A is married and the manager of a local restaurant. Clinical Assessment Mr. A is awake, follows commands, and is oriented to person, place, and time. Mr. A is quiet, shows...
Case study Ahmad is a 74 year old male patient who has been admitted to the...
Case study Ahmad is a 74 year old male patient who has been admitted to the medical ward with acute fatigue, severe shortness, orthopnea and productive cough with hemoptysis. Ahmad's health conditions started to deteriorate since he had an acute myocardial infarction (MI) five years ago. He also presented with lower limbs edema including ankles and feet. According to Ahmad, the edema has started about 1 year since he had the MI. Ahmad also has a history of hypertension and...
A 60-year-old male presents to the ED with a complaint of dyspnea with exertion that has...
A 60-year-old male presents to the ED with a complaint of dyspnea with exertion that has progressively gotten worse over the last 2 months. He also complains of progressive fatigue. HE is in relatively good health, but has a history of GERD and HTN. He has not had any surgeries in the past and his father was diagnosed with colon cancer at the age of 65. He has been training for a marathon for the last 4 months and has...
Mr. W, a 26 year-old man, entered the emergency department with complaints of fever, severe abdominal...
Mr. W, a 26 year-old man, entered the emergency department with complaints of fever, severe abdominal pain, and nausea. He denied any health problems but disclosed a daily intake of four to six beers per day. An abdominal computed tomography (CT) scan performed on admission revealed pancreatic inflammation and intraabdominal ascites. He was admitted to the step-down unit for the management of acute pancreatitis. His treatment plan included intravenous antibiotics, pain control, and management of alcohol withdrawal. Within 48 hours...
An 80-year-old male was brought to the emergency department by his family with the chief complaint...
An 80-year-old male was brought to the emergency department by his family with the chief complaint of “nose bleed.” The patient is taking coumadin under prescription by his internist for chronic atrial fibrillation. The patient is also known to have congestive heart failure. The patient said his nose began bleeding about two hours ago and he was unable to stop the bleeding with other methods he had used in the past. He reported that he had these nose bleeds before...