Clients Initials: M. M.
Room #: 408 Q
Date of Birth: November 29 th 1978
Age: 62
Gender: Female
Admitted to Facility Date: April 13 th 2020
Length of Stay: 2 days
Code Status: Full
Race/ethnicity: White Hispanic
Allergies: NKA
Weight: 45.35kg
Height: 6’3
Admitting Diagnosis: New onset of congestive heart failure and NSTEMI
M. M. is a 62-year-old who reports ineffective breathing pattern, acute on systolic CHF, hypertension, pseudomonas, and thrombocytopenia. They admitted the patient with 4+ lower extremity edema. In his stay in the hospital, he has developed a worsening renal function. The patient reports that the problem started five weeks ago with COPD, Rheumatoid Arthur. The patient was seen at AICD replacement as the patient had Systolic CHF, Septic Shock in August 2015. The patient was prescribed status post-chemotherapy lymphoma and hypothyroidism, but the symptoms did not go away. The patient came back four weeks ago for the same symptoms and was prescribed Dopamine, Norepinephrine, Propofol, and levothyroxine. The patient has a history of COPD and AICD replacement.
The medications that were provided include Dopamine 40 mcg/kg/min IV which therapeutically corrected the hemodynamic imbalances present in the shock syndrome. Major Adverse Effects for the medication are Nausea, vomiting, Azetomia, Dyspnea, and Headache. Nursing Implications is the assessment for signs of dyspnea, vomiting, azotemia, headache, and increased, high blood pressure Also, the patient was added Norepinephrine 4mg/4ml which therapeutically used to Norepinephrine. The major adverse effects: dyspnea and urinary retention. Nursing implications include bradycardia, hypertension, dyspnea, and urinary retention. Propofol 10mg/ml was given to the patient therapeutic include sedation for intubation Major adverse effects include hypertension, heart palpitation, increased heart rate, restlessness, insomnia Nursing implications bradycardia, hypotension, apnea, and dysrhythmias (Sarkar, 2015).
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As for collaborative management care, the physician prescribed the patient medications, and the work of the nurse is to educate and manage the prescribed medications. Other tests that were suggested include x-rays, echo study, and continuous cardiac checking (Lewis, Dirksen, Heitkemper & Butcher, 2014).
References
Lewis, S., Dirksen, S. R., Heitkemper, M., Bucher, L., Harding, M. M., Jeff. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. 10th Edition. Elsevier. [VitalSource Bookshelf]. Retrieved from https://bookshelf.vitalsource.com/#/books/9780323328524/
Sarkar, M. (2015). Auscultation of the respiratory system . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518345/
