M.W. is a 65-year-old female. She is a retired auto worker who lives in a condo with her golden retriever, Charlie. She has a history of diabetes type II diagnosed 3 years ago. She had a myocardial infarction in 2012. She does not exercise. She denies smoking or alcohol use. She was feeling fine until yesterday.
Basic Assessment Data
A&O x4, shortness of breath on exertion, fine crackles in bilateral lower lobes, O2 saturation 89% on RA. S1 and S2 audible without murmur, cap refill >2 secs lower extremities, <2 secs in upper extremities. Vitals: BP 100/60, HR 84, RR 28, Temp 36.1C
Ht: 5’ 5” Wt: 200 lbs.
(10 points) Based on these findings, what type of HF does MW have? Why?
(5 points) What risk factors for HF does MW have?
(5 points) What other manifestations of HF will you assess for?
(10 points) Do you believe her HF is acute or chronic? Why?
(15 points) What nursing diagnoses are most appropriate for MW? Name 3.
(10 points) What nursing diagnosis takes priority? Why?
(10 points) What goals do you have for MW’s care? Name 2.
(25 points) What interventions would you recommend for MW’s priority diagnosis? Name 5 and provide rationale for each.
(10 points) What would you teach MW?