MRS. EDWARDS, A 75 YEAR OLD WOMEN, WAS ADMITTED TO THE MEDICAL UNIT WITH COMPLAINTS DYSPNEA ON EXERTION.

Mrs. Edwards, a 75 year old women, was admitted to the medical unit with complaints dyspnea on exertion.

Subjective data:
-Had a severe myocardial infarction at 62 years of age.
-Has experienced increasing dyspnea on exertion during the last 3 years.
-Recently had a respiratory tract infection, frequent cough, and oedema in legs 2 weeks ago.
-Has to sleep with head elevated on three pillows.
-Does not always remember to take medication.

Objective data:
-In respiratory distress, use of accessory muscles, respiratory rate 36 breaths/min.
-Heart murmur.
-cyanotic lips and extremities.
-Skin cool and diaphoretic.
-Venous leg ulcer on left ankle.
-Bloated abdomen.

Physical Examination:
-Pulse full and bounding= 92 bpm, blood pressure 142/86 mmHg.
-General strength of 4/5 ( 80 % of normal)

Diagnostic studies:
-White cell count ( WBC 15 * 10 /L), BNP normal ( 100 pg/ml ) ; troponin I normal ( 0.01 ng/ml) .
-Chest X-ray result: Cardiomegaly with right and left Ventricular Hypertrophy ; fluid in lower lung fields.
-Ejection fraction 25%.

Collaborative data:
– Digoxin 0.25 mg by mouth once daily.
– Frusemide 40 mg IV twice daily.
– Potassium 40 mmol/L by mouth twice daily.
– Peridopril 8 mg by mouth once daily.
– Low sodium diet.
– Oxygen 6 L/min via Hudson Mask.
– Daily weight.
– Cardiac enzymes every 8 hours * 3.

In addressing this case study you are required to present your paper under four headings:
* Patient History.
– Present a short patient history ( approximately 250 words ). This history should demonstrate the complexities of your clinical specialty area ( Intensive Care Unit ). While the patient problems do not have to be dramatic, it is expected they will provide with an opportunity to demonstrate under the following three assignments headings how you address issues in your selected area of nursing practice ( intensive care unit) using sound clinical judgment, critical analysis and planning to ensure the best patient outcomes.

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