Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol,...

Question

Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol, coronary artery disease (CAD) and Diabetes Mellitus II. He has a 42-year history of smoking 1 pack of cigarettes per day, quit 3 years ago. He is a retired truck driver who lives in a retirement community. He was brought into the emergency department (ED) by a friend after complaining of a massive headache, 10 out of 10, which felt like a “tight headband” around his head.

Mr. Johnson stated that his pain had increased as the day progressed. Vital signs upon intake revealed the following: 188/104, 108 BPM, 22 RR, 93%, 99.2F, when questioning the patient about the events leading up to this morning, he stated that he did not take his “water pill” or medications that his doctor prescribed. He added that he stopped the water pill because he keeps going to the bathroom, and is unable to sleep at night. He states he is on several heart medications. He did not bring any of his medication with him to the emergency department ED.

Physician’s orders included:

A saline lock, (inserted into the right forearm)
12 lead EKG (revealed sinus tachycardia)
Computed tomography (CT) scan of the head (revealed normal findings)
Enalapril 1.25 mg IV (administered in the ED)
Hydrocodone 5mg/325 mg (2 tablets) PO (administered in the ED)
Admit to the telemetry unit for further observation.

Questions:

What are the abnormal assessment findings for this patient?
Develop 2 priority nursing diagnoses (3-part phrases) for this patient.
What is 1 at risk nursing diagnosis for this patient?
What are the diagnostic tests performed for this patient and what were revealed from each test?
What are possible patient-centered goals for each of the chosen diagnoses?

Interventions

What are some non-pharmacological interventions that the nurse should perform for this patient?

 · Answer

1.Abnormal assessment findings are vital signs.Hypertension, tachycardia and low saturation level.

2. Headache related to physiological changes in the body as evidenced by pain scale score.

Tachycardia related to pain as evidenced by checking pulse rate 108.

3.Risk for decreased cardiac output related increased blood pressure.

4.EKG shows sinus tachycardia.

CT shows normal study.

5.Goals are to reduce pain .It is the need of the patient.Hence it is patient centered goal.

6. Advice to have diversion like music therapy.

.

Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol,...

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