Nursing Process Paper

Topics: Hypertension, Myocardial infarction, Heart failure Pages: 8 (2695 words) Published: January 23, 2011

Nursing Process Paper

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may occur. This paper will also identify and describe significant events that occurred during the patient’s hospital stay with support of explanation with evidence from signs and symptoms and diagnostic tests. Also, there will be a description of the client’s condition at the time of my care including medicines and other physician ordered interventions and explanation of reason each was instituted. Three nursing diagnoses will be identified for this client, each with measurable client goals, interdisciplinary interventions, and patient outcomes. This paper will also provide a comprehensive description of the client’s illness on the individual, family and society, economically, socially, spiritually, emotionally, and the effects on family roles. In conclusion, the paper will end with the identification of a clinical or nursing practice problem related to the care of the client posed in the form of a nursing research question. Complete explanation of the rationale for this problem and a review of the literature and synthesis of the findings from two research articles which are related to the research question will be provided.

Introduction and History
Discussion of relevant acute and chronic problems leading to admission to the hospital
On October 17, 2010, D.S. was admitted to the hospital due to difficulty breathing and HF exacerbation. The patient states she was at home, but had increasing shortness of breath and then difficulty getting around to the bathroom. She is currently living at an assisted living home in Byron and is on supplemental oxygen there. Her admitting vital signs were T 98.2, P 100, R 20, and BP 141/60. The patient had recently been admitted to the hospital in September with these same complaints and suspected CHF and had some simple spirometry performed at her doctor’s office in May of this year. In May, her spirometry showed an FVC of 1.97 L (72%), an FEV1 of 1.26 L (72%), and an FEV1/FVC ratio of 64%. To determine whether airway obstruction or a restrictive process is causing a reduced FEV1, the FEV1/FVC ratio is the answer. A low FEV1 and a decreased ratio signify a predominantly obstructive process (Hyatt, Scanlon, Nakamura, 2003). The patient has a history of emphysema and smoked one to two packs a day for thirty years before quitting twenty years ago. So in this case, her pulmonary function is decreased due to these processes. Also in May, a CT of her abdomen did show some questionable mild increased interstitial densities in the posterior aspect of the lungs at the bases, which might be indicative of possible early interstitial lung disease. In September, when she admitted for shortness of breath and suspected CHF, she underwent an ischemic workup and an echocardiogram was found to have no ischemia with a normal ejection fraction. She was found to have right atrial enlargement, left atrial dilatation, moderate aortic valve sclerosis without stenosis, trace mitral regurgitation, mild mitral stenosis and mild tricuspid regurgitation as well as moderate pulmonary hypertension.

D.S. is an 84 year old Caucasian female with a past medical history of chronic obstructive pulmonary disease (COPD), emphysema, congestive heart failure (CHF), hypertension (HTN),...
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