Med Surge Process Paper
Nur122-201 Human Needs in Health and Illness II
Patient is an 80 year old female and her initials are ERH. She is a white, protestant, widow who currently lives at home with her daughter-in-law and grand-daughter. They live in a rancher style home with a wide landing and steps that enable her to use her walker to ambulate in her home. Her birthdate is June 14, 1931. During the initial assessment with the patient, she said that she was formerly employed with the Singer Sewing Machine Company as a book-keeper for 17 years. Upon retirement she and her husband moved back to Delaware and opened one of the first video stores in the state. Patient stated that their ...view middle of the document...
5 mg |1 tablet |MI history |
|Lasix |IV |40 mg | |Edema/CHF |
The following chart is a list of all as needed medications.
|Medication |Route |Dose |Amount |Reason patient is taking |
|Acetaminophen |PO |650 mg |2 tablets |Pain relief |
|Morphine |IV |1 mg |0.5 mL |Pain relief |
|Nitroglycerin SL |Sublingual |.4 mg |1 tablet |Chest pain/CHF |
|Albuterol 0.083 % |Nebulized |2.5 mg |3 mL |Bronchorestriction |
|Diphenhydramine |PO |25 mg |1 capsule |Itching |
|Hydroxyzine |PO |25 mg |1 tablet |Itching |
The patient’s past diagnoses are methicillin-resistant Staphylococcus aureus (MRSA), atrial fibrillation, cellulitis and abscesses of the leg, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, melanoma, myocardial infarction and transient ischemic attack.
Patient’s primary diagnosis is congestive heart failure. Heart failure occurs when the heart cannot fill and contract effectively and does not have the strength that is needed to function well enough to meet the body’s needs. Heart failure is classified as a disorder of cardiac function. It often is due to impaired myocardial contraction, which could result from coronary heart disease and myocardial ischemia or infarct or from a primary cardiac muscle disorder such as cardiomyopathy or myocarditis. Structural cardiac disorders, such as valve disorders or congenital heart defects, and hypertension can also lead to heart failure when the heart muscle is damaged by the long-standing excessive workload associated with these conditions. Other patients may present with manifestations of heart failure due to acute excess demands placed on the myocardium, such as volume overload, hyperthyroidism, and massive pulmonary embolus. Hypertension and coronary heart disease are the leading causes of heart failure in the United States. African Americans have a high prevalence of hypertension and that significantly increases their risk for incidence of heart disease (LeMone, Burke & Bauldoff, 2011).
The pathophysiology of congestive heart failure is when the heart begins the fail, mechanisms are activated to make up for the impaired function and sustain the cardiac output. The...