Understanding Medical Surgical Nursing 5th Edition by Linda Williams, Paula Hopper

تمرين 1

Smith
Mrs. Smith, age 78, baseline weight 162 pounds, is admitted to the hospital with shortness of breath. Initial assessment findings are BP 152/88 mm Hg, pulse 104 beats per minute, respirations 26 per minute, temperature 99.4°F (37.2°C), shortness of breath at rest that increases with activity, ankles swollen, heart tones distant, nailbeds pale, no pain, has not eaten well for 2 weeks, 6-pound weight gain in 1 week, sleeps on three pillows, neck veins visible bilaterally. A diagnosis of acute MI with heart failure is made by her HCP.
1. Why might Mrs. Smith not be having chest pain with a diagnosis of acute MI?
2. How should swollen ankles be assessed to provide complete and measurable data?
3. What should be documented for the assessment performed on the swollen ankles and how should the assessment findings be documented?
4. How should the assessment findings be documented for the additional symptoms Mrs. Smith has?
5. What is Mrs. Smith's weight in kilograms?
6. What health care team members might provide collaborative care for Mrs. Smith?