Client Composite

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Well researched client history:
Diagnoses defined:
Congestive Heart Failure (CHF) –
Orthopnea –
Acute Coronay Syndrome –
Diabetes –
Hypertension –
Acute anxiety –
Chronic depression –
Past and present health status:
Present: Chronically ill (see diagnoses above)
Past: COPD, peripheral vascular disease (no surgery due to medical condition), acute coronary syndrome (Jul ’08), previous rt carotid endarterectomy, CVA, hypertension for many years, and type II diabetes for more than 15yrs. Family, support systems, community, occupation:

Lives with female friend who helps her with her poor balance and walking. Good family support; observed daughter, son in law and granddaughter sit with her in hospital How client assess the health care system:

Summary of medical treatments, procedures, diagnostic tests
Medical treatments: O2 4L; Bipap prn; narcotics (morphine fast acting via IV, and long acting 24hr PO); insulin sliding scale; all meds Procedures:
Diagnostic tests: MUGA scan;
How have these results affected your client’s health status? Client is not doing well. Night of the 28th she was tachycardia. 29th day she was extremely fatigued and slept most of the day due to morphine and Gravol. Blood glucose levels fluctuated from critically low to critically high. Before Gravol was administered she responded to verbal cues; after Gravol, she was difficult to wake. Describe the client’s feelings and /or concerns about the medical condition Describe the effect of the condition on the client’s quality of life: effects ADLs as client is in pain possibly due to lungs (edematous), ACS; she has been confused since acute coronary syndrome in Jul 2008 and therefore needs constant monitoring as far as ADLs and medication. She has chronic complaints of shortness of breath and severe fatigue Describe how the condition affects family life

Describe what is similar and what is different about the client’s history and the description in the literature...
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