[kleona]

Mr. D. 64 yo male with hx. of COPD, HTN, Type II DM. He has just arrived this from the EC with the diagnosis of uncontrolled HTN, (Admitting BP was 220/110), and Chest Pain. The symptoms that brought him into the EC were severe morning H/A with occasional vomiting X 3 days, SOB and C.P.

When you examine him you notice a large bruise on his right elbow and hip. He relays a H/O a fall recently. He complains of dysphagia which he attributes to a sore throat from vomiting. He ia slightly disorientated and drowsy, but received a dose of Zofran for vomiting before he was brought up to your unit.His HA has returned but he feels he can not take anything po because of his earlier vomiting.

• Labs: Na: 145, K: 3.7, Cl:110, C02: 30, BUN: 22, CRT: 1.5, BS 210
• Hgb 12.7, WBC: 10.3, PLTS: 110. troponin <0.03
• Chest X-Ray: No effusions, or pnemonia, but emysematous changes noted
• Current BP: 156/98 HR:78 reg., RR: 24 on 4L O2

What could be happening to Mr. D.? Is all his symptoms related to HTN?


Thank you all of you!!

[nurseaboveboard]

Some ideas to ponder: Patient c/o headache and vomiting plus recent fall? Possibly neuro? Hope they did a CT of head too? This patient has a terrible history, a veritable "train wreck" as they say. I think HTN is just one of his problems! Also, any history of alcohol abuse? Fall could be related to this, which they oft won't admit? For sure doesn't sound like he's taking care of himself!

[NancyNurse08]

Did he abruptly stop taking beta blockers?

[sirI]

What do you think could be going on, kleona?

Let us know your thoughts on this and rationale(s).

[Daytonite]

You need to apply the nursing process to critically think through this situation. This is something you will be doing 5, 10, 20, 50 times a day at your job as an RN when you finally get your license. The steps of the nursing process are:

1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADL's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
2. Determination of the patient's problem(s)/Nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

and you must follow them in that sequence.

So, the first thing you must do is assess the patient. Since this is a case scenario, most of the assessment data has been given to you, so go through the scenario and make a list of the abnormal assessment data there:

• admitting BP was 220/110; Current BP: 156/98 HR:78 reg., RR: 24 on 4L O2
• chest pain
• severe morning headache
• occasional vomiting X 3 days
• SOB
• large bruise on his right elbow and hip (fell recently)
• complains of dysphagia which he attributes to a sore throat from vomiting
• slightly disorientated and drowsy (received a dose of Zofran for vomiting)
• BUN: 22 (normal 10-20) 856
• creatinine: 1.5 (normal 0.6-1.2)
• blood sugar 210 (normal 70-105)
• Hgb 12.7 (normal 14-18)
• WBC: 10.3 (very slight elevation)
• Platelets: 110 (normal 150-400)
• Chest X-Ray: emphysematous changes noted

Next, you need to look up information about his medical diagnoses. You want to know their usual symptoms, complications and their pathophysiology. You already know from the information provided about his chest x-ray that the type of COPD that he has is emphysema:

• uncontrolled HTN
• COPD (emphysema type)
• Type II DM

Now, make a list of all the symptoms this patient has and add those that he may also have that you discovered from your reading about his three medical diseases. Look at the list and see if there is a way that you can group some of these symptoms together with others. For example, you will have some symptoms that will definitely be respiratory in nature, so put them together. Put the GI symptoms together. Etc. You will find that some of the symptoms are symptoms of his COPD, HTN, or diabetes. In your reading about his three medical diagnoses, did any particular symptoms stand out? In particular, I am referring to the symptom of "severe morning headache". This is a very specific symptom of a particular medical condition. See if you can find out what medical condition it belongs to. I also see a correlation between the low platelet count and the bruise on his elbow and hip from an earlier fall. What's going on there? He also has a low hemoglobin. Does he have some occult bleeding going on somewhere? What are the complications of hypertension if left untreated? Could the complications of emphysema be in any way related to his hypertension? These are questions you need to be asking yourself and that you should be finding in your reading about his diseases.

Have fun!

[bluesky]

Originally Posted by kleona

Mr. D. 64 yo male with hx. of COPD, HTN, Type II DM. He has just arrived this from the EC with the diagnosis of uncontrolled HTN, (Admitting BP was 220/110), and Chest Pain. The symptoms that brought him into the EC were severe morning H/A with occasional vomiting X 3 days, SOB and C.P.

When you examine him you notice a large bruise on his right elbow and hip. He relays a H/O a fall recently. He complains of dysphagia which he attributes to a sore throat from vomiting. He ia slightly disorientated and drowsy, but received a dose of Zofran for vomiting before he was brought up to your unit.His HA has returned but he feels he can not take anything po because of his earlier vomiting.

• Labs: Na: 145, K: 3.7, Cl:110, C02: 30, BUN: 22, CRT: 1.5, BS 210
• Hgb 12.7, WBC: 10.3, PLTS: 110. troponin <0.03
• Chest X-Ray: No effusions, or pnemonia, but emysematous changes noted
• Current BP: 156/98 HR:78 reg., RR: 24 on 4L O2

What could be happening to Mr. D.? Is all his symptoms related to HTN?


Thank you all of you!!

Nothing personal but I am not here to either

1) be quoted in your lawsuit

or

2) do your nursing school or critical care fellowship homework


sorry!

[cardiacRN2006]

Originally Posted by bluesky

Nothing personal but I am not here to either

1) be quoted in your lawsuit

or

2) do your nursing school or critical care fellowship homework


sorry!

Thank you. This is a pet peeve of mine as well, and yet there will always be someone here willing to do a students homework for them...
Ugh...

[kleona]

No one is obligated to answer.

I thank 100% all of you who helped. You are real nurses: caring, helpful,wonderful and beautiful people. I am almost done with Nursing school and I would do the same thing for others. God bless your hearts.



Kleona

[Valerie Salva]

Originally Posted by cardiacRN2006

Thank you. This is a pet peeve of mine as well, and yet there will always be someone here willing to do a students homework for them...
Ugh...

I agree. How on earth did any of us ever seasoned nurses make it? I mean there was no internet- we had to do all of our work ourselves.

[Valerie Salva]

Originally Posted by kleona

No one is obligated to answer.

I thank 100% all of you who helped. You are real nurses: caring, helpful,wonderful and beautiful people. I am almost done with Nursing school and I would do the same thing for others. God bless your hearts.



Kleona

No offense intended, but you need to be able to do it for yourself, first.