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Posted about 3 years ago
Hello everyone! I'm not sure if it correct place for my question, if not I hope moderator will move to right place.
I'm working on Case Study.
Pt second day in hospital after acute anterior MI. Her WBC 14.5 and HCO3 19, other labwork within normal levels. VS T99.6, P118, R24, BP 172/92. Biox 98% on 5L Fine crackles in the bases of both lungs, auscultation reveals S4.ECG -sinus tachycardia with occasional PVC's. Skin is cool and diaphoretic. Capillary refill <3, periph. pulses are strong and edual. She has a Foley, urine is yellow and clear.She has peripheral IV and central line, triple lume, in right subclavian, infusing Nirtolgycerin, alteplase, and heparin. She rated her pain 9 from 0 to 10, after morphine shot she rates it 4 from 0 to 10. She is hoping to discharge soon, so she can smoke again. She has type 2 diabetes and hypertension. I need to prioritize 3 nursing diagnoses.
This is what I think
#1 Pain, Acute R/T myocardial ischemia AEB patient has severe chest pain, radiation of the pain to her jaw and left arm.
Patient rated her pain a 9 from 0 to 10 scale. After pain medication she states that pain is better, but it have been coming and going.
Rational: acute pain may cause high blood pressure, anxiety, breathing and other problems. Pain is always one of the priority problems. When patient is in pain it hard to do something else, eat, sleep and move. It will create other problem with mobility, rest and nutrition.
#2 Decreased cardiac output R/T ventricular damage, ischemia AEB patient has clammy skin, crackles in her lungs, S4 sounds.
Her skin is cool and diaphoretic. She has altered heart contractility, auscultation reveals an S4 and fine crackles in the base of both lungs.
Rational: I put this problem #2 because patient with decreased cardiac output has inadequate volume of blood pumped by heart. As a result metabolic demands of the body doesn’t meet. We don’t have pH data, but patient HCO3 is low 19mmol/l, it may put patient in acidosis state.
And I want #3 Risk for infection R/T invasive procedures (central line, peripheral IV, Foley) and she may be exposed tp pathogens.
I never good with prioritizing, I need some help. Am I on correct patch? Thanks