What Client History & Assessment Data help support your priority diagnoses?

nursing

Description

DB #2 CAD, MI, HF

Mr Sullivan: Adult CAD, MI, HF

 

Mr. Sullivan, a 79 y/o current 1 pk/day smoker for over 50 yrs, has the diagnoses of Hypertension (HTN), Hyperlipidemia (HLD) & a relative new diagnosis of Coronary Artery Disease (CAD) having had a Non ST Elevation Myocardial Infarction (NSTEMI) 4 weeks ago.  He presents to the Health Clinic today for a routine follow-up following his MI. 

 

He tells the Health Care Provider that he is short of breath (SOB) lately, has been sleeping in the recliner for the past week as he would wake up when sleeping in his bed, with air hunger.  He tells you that he now gets SOB walking up the driveway after retrieving his newspaper in the morning. He also tells you that his socks are quite tight around his ankles & his shoes seem too small.

 

He has no medication or food allergies. Home medications include: EC ASA 81 mg daily, clopidogrel 75 mg daily, metoprolol tartrate 50 mg q 12 hr, lisinopril 5 mg daily, atorvastatin 40 mg hs, and NTG SL prn chest pain.

 

Vital Signs:  BP 156/88, HR 110, RR 26, POX 90% RA, Temp 97.8.  Weight 89 kg today; on hospital discharge weight documented at 81 kg.

Physical Assessment:  Neuro A & O x3; Neck +JVD to the ear lobe; Lungs crackles throughout; Heart Sounds regular, tachycardic, S3, S1,S2, no murmurs appreciated; Abd soft, nontender, non-distended, bowel sounds +; Extremities PP+, 3+ pitting pedal edema.

 

Response to the Questions:

  1. Explain the pathophysiology r/t to the top 2 priority diagnoses.
  2. What Client History & Assessment Data help support your priority diagnoses?
  3. Do all the clients medical diagnoses link together?  If so how?



Related Questions in nursing category


Disclaimer
The ready solutions purchased from Library are already used solutions. Please do not submit them directly as it may lead to plagiarism. Once paid, the solution file download link will be sent to your provided email. Please either use them for learning purpose or re-write them in your own language. In case if you haven't get the email, do let us know via chat support.