Posted: July 22nd, 2021

Reflection – Care Map for Patient with Irregular Heart Rate

Nursing Idea Care Map Task

●       Affected person Title: P.S.

●       Age: 56-years

●       Gender: Male

●       Peak: 5’ 10”

●       Weight: 150 lbs, 68 kg

●       Faith: Catholic

●       Occupation: Affected person works at a Pharmaceutical firm within the Manufacturing division.

a)      Present remedy: Affected person is at present handled for irregular coronary heart charge and rhythm with hypertension and decreased peripheral pulse. He additionally has a historical past of Myocardial Infarction (MI) which was identified on the age of 51.

b)     Present drugs: Prescription Amlodipine Besylate 5mg P.O. q.d. (as soon as a day)

          Aspirin 150mg P.O. q.d. (as soon as a day)

      2.   Household Historical past

●       Brother was identified with Bronchial asthma on the age 45, 1972.

●       Grandfather was identified with lung most cancers at age 60.

●       Father and mom has a clear well being historical past.

●       Siblings, Aunt and Uncle has a clear well being historical past.

      three. Present way of life practices

●       Food plan: Eats wholesome meals as current. However eats fried meals a couple of times a month.

●       Exercise: Train as soon as every week or as soon as each two weeks for 1 hour.

●       Sleep Patterns: 5-6 hours per evening. Has orthopnea (must sleep in upright place with three pillows)

●       Elimination patterns: Urinates 5-6x a day and bowel elimination 1-2x a day. Affected person acknowledged, “Often has bowel actions each different day.” 

●       Alcohol consumption: None

●       Smoking: 1 pack in two weeks. 

●       Leisure medicine: None

●       Annual bodily examination: Affected person’s annual test ups are up-to-date with the newest Bodily examination every week in the past. Has bilateral +2 pedal edema. Decreased peripheral pulse (Radial pulse +1 bilaterally; pedal pulse +1 bilaterally). Irregular coronary heart sound (S3) 

●       Dental examination: 1 12 months in the past with no problems.

●       Gynecologist Prostate examination: 2 years in the past with no irregular findings.

      four. Well being Habits

●       Eats vegetables and fruit. Hardly ever eats fried meals. Drink a ample quantity of fluids similar to water, orange juice and protein milk. Walks as soon as every week and train each morning.   

      5. Well being issues

●       Affected person acknowledged, “I'm drained on a regular basis and I've no vitality.”

●       Affected person acknowledged, “I attempted to chop down on smoking however failed at it. I've a cough and really feel wanting breath more often than not.” 

      6. Addressing issues

●       Nervous about one other coronary heart failure. Addresses his concern about shortness of breath as a consequence of smoking.

     7. What would the affected person like to enhance about his general well being?

●       Quit smoking to keep away from danger of lung failure.

●       Begin consuming extra contemporary greens and fruits, low sodium weight loss program and avoiding fried meals. Keep hydrated.

●       Affected person acknowledged, “I wish to train and stroll not less than twice every week.”

B. Doc the Well being Historical past

P.S. is a 56-year-old male whose peak is 5’ 10’’ and weighs 150 lbs. He was admitted to the       hospital as a consequence of irregular coronary heart charge and rhythm and modifications in Electrocardiogram (ECG) indicating irritability of the guts failure. He additionally had a hypertension. He has a historical past of Myocardial Infarction (MI) at age 51. Apart from this, Mr. P.S. reviews, “I'm drained on a regular basis. I've no vitality.” He has bilateral +2 pedal edema, decreased peripheral pulse (radial pulse +1 bilaterally; pedal pulse +1 bilaterally), orthopnea (must sleep in an upright place with three pillows), and audible S3 coronary heart sound (additional coronary heart sound which signifies coronary heart failure). He urinates 5-6x a day and has bowel actions each different day (1-2x a day). Mr. P.S. reviews, “I attempted to chop down on smoking however failed at it. I've a cough and really feel shortness of breath more often than not. I've issues with catching my breath.” Respiratory charge is 27/min; pulse oximetry is 91%; no cyanosis famous. He has a nutritious diet with fruits and juices as of now. His regular weight loss program consists of protein, entire grains, low-fat dairy merchandise and low sodium weight loss program, however eats fried, and unhealthy meals twice a month. The affected person doesn’t take part in any leisure medicine however smokes one pack in two weeks. Final bodily examination was every week in the past with some problems similar to edema, decreased pulse and irregular coronary heart sound (S3). Affected person was engaged in weekly train and strolling to take care of his well being. He's at present admitted for remedy of cardiac irregularities and coronary heart failure.

C. Checklist of potential Nursing Prognosis

●       Decreased Cardiac Output

➢      Subjective Knowledge

Affected person acknowledged, “I'm all drained. I've no vitality.” 

Affected person acknowledged, “I've a cough and really feel shortness of breath more often than not.”

Affected person acknowledged, “I've issues catching my breath.”

➢      Goal Date

Affected person has irregular coronary heart charge and rhythm and modifications within the ECG.

Decreased peripheral pulse radial +1 bilaterally, pedal +1 bilaterally.

Pulse oximetry was 91%. Affected person has hypoxia (lack of oxygen)

Affected person has an additional coronary heart sound S3 which signifies coronary heart failure.

●       Ineffective Respiration Sample

➢      Subjective Knowledge

Affected person acknowledged, “I'm drained on a regular basis and don't have any vitality.”

Affected person acknowledged, “I've issues catching my breath.”

Affected person acknowledged, “I've a cough and really feel shortness of breath more often than not.”

➢      Goal Knowledge

On examination affected person’s respiratory charge was 27/min.

Upon auscultation affected person has crackles on the lung bases bilaterally.

●       Danger for Pulmonary Associated Illnesses

➢      Subjective Knowledge

Affected person acknowledged, “I've issues catching my breath.”

Affected person acknowledged, “I attempted to chop down on smoking however failed at it. I've a cough and really feel shortness of breath more often than not. I've issues with catching my breath.”

➢      Goal Knowledge

Smoking as soon as every week reveals the elevated danger of pulmonary illnesses and lung most cancers.

●       Exercise Intolerance

➢      Subjective Knowledge

Affected person acknowledged, “I'm drained on a regular basis and don't have any vitality.”

➢      Goal Knowledge

Affected person has decreased peripheral pulse, radial +1 bilaterally and pedal +1 bilaterally.

Bilateral +2 Edema. Respiratory charge is 27/min with pulse oximetry 91%.

Precedence Nursing Prognosis

Decreased Cardiac Output r/t hypoxia aeb (as evidenced by) irregular coronary heart charge and rhythm. Based mostly on the affected person’s situation Decreased Cardiac Output is the precedence nursing analysis because the affected person has cardiac irregularities, low pulse oximetry 91% and excessive respiratory charge 27/min. That is evidenced by affected person acknowledged, “I really feel shortness of breath and drained on a regular basis.”

The Interview Expertise

The expertise of conducting a well being historical past on a affected person was difficult in addition to an unlimited studying expertise. I went to a rehabilitation middle for conducting an interview. This was my first time conducting a well being historical past interview so I used to be nervous. First I believed it was simply an interview and can be very easy. However as I began asking questions it was difficult and required nice persistence and communication abilities. Growing belief is essential to get acceptable well being info from the affected person. My verbal communication abilities helped me in searching for correct well being info from the affected person. As I requested questions concerning the affected person’s situation I might correlate all of the analysis efficient for my idea map.

Probably the most difficult half was accumulating info which was measurable and exact. After accumulating the data I needed to assume critically how you can plan, implement and consider the nursing analysis. This was my first time interviewing so, I wasn’t capable of ask extra particular questions concerning the indicators and signs of the illness which made tough for me to critically assume and relate all of the analysis and determine on a care plan. What I'd do in another way subsequent time is, I'd ask extra exact details about their way of life and consuming habits. I'd additionally ask their chief concern concerning the illness and extra particular details about searching for well being care. This might assist me create an analysis which is measurable, reasonable and time framed.

This task was a superb and an incredible expertise for me to take a look at the nursing course of in a broad method.

Conclusion

General, I by no means thought that getting affected person’s well being historical past was crucial for making a analysis. I used to fill the well being historical past kind only for the sake of filling, however now I understand how vital it's for the medical doctors and nurses to make an acceptable course of remedy for the affected person. It is necessary that we all know the affected person's issues and danger elements for a specific illness. To know that, we must always have correct information of the affected person's present well being standing, previous medical historical past and affected person’s complaints. One other issue which I realized is communication. If you wish to receive acceptable info from the affected person, it is very important construct a belief between you and the affected person in order that he/she is ready to share any well being issues with you. Fundamentals of the well being historical past are crucial to determine on a care plan. From this task I realized that it is very important receive well being historical past from a affected person and the way every an each danger issue is vital for analysis. This was an enlightening expertise for me and I actually felt like a nurse for a second. Thanks for implementing this task as a course of examine for the Nursing program.   

References

  • Ackley, B. J., & Ladwig, G. B. (2015). Nursing analysis handbook: an evidence-based information to planning care. Tenth version. Maryland Heights, Missouri: Mosby Elsevier.

 

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