Nursing Case Study Essay
Najla Morshidi NURS 301 Case Study
Health History and Analysis of Finding
A 75 year old female patient alert and oriented X 3, weigh 115 Lbs, her height 5?8??, has a hearing aid and wear glasses for reading. The presented Patient has a history of hypertension diagnosed with CHF on 2013, positive for Hepatitis B due to contaminated blood transfusion. Had a cervical dysplasia on 1994 resolved by a total abdominal hysterectomy and bilateral oophorectomy the following year. The patient was diagnosed for polyps and multiple diverticula at the age of 68. The Patient suffers of painful osteoarthritis of both knees, shoulder hips. Patient?s mother deceased at the age of 79 from breast cancer and her father deceased at the age of 54 from heart attack.
The patient noted with bilateral lower extremities edema, and claimed that she uses 2 pillows as a comfortable position to sleep,
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The desired outcome will be having the patient with clear lung sounds, edema free and denies dyspnea on exertion. To achieve these outcomes we need to monitor body weight daily, ?changes in bodyweight reflect changes in body fluid volume? (Methney, 2010). Mean time we need to monitor extension and location of edema? causes of peripheral edema in patients with heart failure are related to compensatory changes that influence hydrostatic pressure and fluid retention? (Cooper 2011). Input and Output need to be monitored ?accurate measuring for intake and output is important for the client with fluid overload.? (Metheny 2010). Listening to lung sounds and report abnormal findings like crackles allow the prevention of pulmonary edema and occurrence of pneumonia due to fluid
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