Diagnoses Case Study.

Fluid overload

Scholarly references:

At least 20 scholarly references from 2009 to 2019. The appropriate referencing style for this unit is APA Style

Patient situation:

Mr Clive Jenkins is a 78 year old retired navy engineer. He has a past medical history of Congestive Cardiac Failure (CCF), which developed after suffering a severe myocardial infarction (MI) 2 years ago. The MI affected both ventricles. He has recently been diagnosed with Dementia and as a result, it has been difficult for him to sustain the necessary life-style adjustments required to prevent exacerbations of CCF. This has resulted in several admissions to hospital for management and review of his CCF. For this admission, Mr Jenkins was referred to hospital by his GP after gaining 3kg since his last visit only one week prior, moving from 92kg to 95 kg. The time now is 0800 and you have just come on for your morning shift. Mr Jenkins has been on the ward for only two hours after spending 18 hours in emergency waiting for a bed to become available. Collect cues:

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1. Review the documentation available to you

There are existing documents including: Observation chart, the Progress note, fluid balance chart, IV fluid orders, medication chart, and the general practitioner letter attached in the next documents.

2. Gather further information You undertake additional assessments to gather new information, recording the following data:

You undertake additional assessments to gather new information, recording the following data:

Vital signs: • BP: 150/90 • Pulse: 112 bpm • RR: 24 • Sp02: 94% on 2L via nasal prongs • Temp: afebrile

• Mr Jenkins appears ‘pleasantly confused’. When repositioning himself in bed he becomes short of breath. He is reluctant to get up as he feels so tired. You also note he has already drunk the 1 litre jug of water provided to him when he arrived on the ward.

Other data: • BGL within normal range • GCS: 14 (confused • Peripheral pulses difficult to palpate, presence of pitting oedema bilaterally. Rash on

left leg. Capillary return > 4 seconds.

• Current weight 97kg • Raised and visible JVP (Jugular Venour Pressure) • Passing urine in a bottle • Abdomen soft and non-tender. Bowel sounds present.

Written Assignment (2000 words)

A compulsory approach would be: 1. Interpret:

List the data that you consider to be normal/abnormal in the area provided. Ensure that you provide normal reference ranges for abnormal data, and a citation for your source. Normal (Subjective & Objective) Abnormal (Subjective & Objective)

2. Process the information (350 words) You have to answer all of these questions and follow the instruction below to write : On this patient, you have to explain the mechanisms and consequences of fluid overload both chronic and acute, and consider why the acute occurrence has occurred Relate and Infer is about clustering the cues, and explaining your patient’s presentation. What abnormal cues are evident, and what are the mechanisms which have resulted in those cues? How does CCF influence renal function? What are the consequences? Why has Mr Jenkins gained 3kg in one week? Why do you think his RR is elevated? Why do you think his SpO2 is 94% on 2L of O2? Why do you think he is “Breathless on exertion”? Does this have any connection to the missed medication administration? What would those drugs have done for him if they had been administered?

a. Relate: o Cluster all cues and recognizes the pattern relating to the suspected problem

underlying the case. o After clustering the cues together and to identify relationships between them.

After that, recognising and supporting a problem that you think might be occurring with this patient.

o List abnormal findings that you think is the most significant. Relate your identified abnormal findings to the underlying physiology, pathophysiology and explain why you think they are the most significant health issue.

b. Infer:

o From what you know about the patient’s background, the cues that you have clustered, and the signs and symptoms the patient experiencing, explain your interpretation of patient condition: what is going on in this patient. Provide relevant scholarly references.

▪ You have to make a suggestion based on analysis of the case to make logical inference about what patient is experiencing.

▪ You have to form an opinion that logically follows on from the cue clustering and state the problem in a concluding sentence

o Make deductions as to why a cue, or a cluster of cues may be considered

abnormal in this context. Justify by referring to the relevant anatomy, physiology and pathophysiology.

o What do you think the reason for the patient’s health issue? Relate the cause of the health issue to the principle of biomedical knowledge (focus on structural and functional perspectives). Provide reference details.

3. Predict:

Explain what may happen to your patient if no action is taken. You also have to refer to pathology and pathophysiology that is contributing to the patient’s health condition. Provide reference details. (100 words)

4. List in order of priority at least 5 nursing diagnoses. You also have to explain why you choose your two highest priority nursing diagnoses in this patient’s condition. (100 words ) For examples : 2 highest Nursing diagnoses here can be fluid retention or peripheral oedemna Required: You have to use the cues in the case study to identify the related and high-risk factors, and characteristics to formulate the priority nursing problem then lead to 2 highest priority nursing diagnoses. You have to explain based on that.

5. Identifying the problem(s), Establishing Goals, Taking Actions, Evaluating Outcomes. (1450 words)

Based on your understanding of your patient’s current situation you must now:

• for each of your three (3) highest priority nursing diagnoses o establish two (2) goals. o list 4-5 related actions you would undertake to achieve that goal o provide a rationale for each action that associates the pathophysiological and

psychological principles with each action. Support your rationale with evidence from the literature.

Diagnoses Case Study.

o describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient). You have to provide the reference details here.