EH is a 70-year-old widowed Hispanic retired seamstress admitted to the medical
ID: 126640 • Letter: E
Question
EH is a 70-year-old widowed Hispanic retired seamstress admitted to the medical unit with increasing dyspnea on exertion. Her history is significant for a MI at age 58 years old. She retired two years ago for her long-term occupation when the commute to and from work became too much exertion for her. Since retiring, her daily activity decreased without the routine and structure of going to work. Her breathing progressively worsened further limiting her mobility as she could no longer walk the two blocks to the corner store. Her ability to attend to her ADLs (activities of daily living) also diminished due to her breathing difficulties. Two weeks ago, she developed a respiratory infection that was treated with a total of 10 days of amoxicillin clavulanate 875mg twice daily, but despite completing the full course, her respiratory status continued to decompensate now aggravated by a frequent cough and bilateral pitting lower extremity edema approximately 2-3+. This morning arriving to visit her mother, Mrs. H was clearly struggling to breathe. She activated EMS through her cell phone. After assessment and treatment in the Emergency Room, Mrs. H arrives on the medical unit. Lying on the stretcher with three pillows elevating her torso to 75 degrees, clutching her daughter’s hand, and wearing oxygen at 6L per minute, her respiratory rate is about 36 breaths per minute with obvious accessory muscles to breath. You deftly move to do your nursing assessment, finding moist crackles bilaterally in both lower lung fields, her lips are a dusty blue-ish purple, she is diaphoretic, and her skin is cool to touch. Her heart rate is 104 beats per minute, and her blood pressure is 177/88. Acutely ill, but stable from your assessment, the results of her chest x-ray showed cardiomegaly with both right and left ventricular hypertrophy and fluid in both lower lung lobes. As per the notes from the ER, Mrs. H was given:
digoxin 0.25mg oral once
furosemide (Lasix) 40mg intravenous push once
potassium 40 mEq orally once and another 40 mEq ordered with food for this evening
enalapril (Vasotec) 5mg orally once
1. For the priority human need or nursing domain selected:
a. Write one specific measurable goal addressing this need or domain.
b. List at least three nursing interventions addressing this need or domain.
c. The interventions must be referenced in 6th Edition APA format from at least one appropriate nursing,
medical, or healthcare journal within the past five years (2012-2017); if the citation is older than five
years, it should be considered a classic citation.
d. Write a 4th nursing intervention that is your own idea fitting the context of this case scenario. This
is the creative component of nursing. The intervention can be referenced, if not your own words; however, a citation is not required for the 4th intervention.
Explanation / Answer
a) goal
limit myocardial damage by restoring myocardial blood flow, noraml blood pressure level, and maintain normal breathing pattern.
b)nursing interventions
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