Assessment of Cardiac Status
Assessment of Cardiac Status
Esther Jackson is a 56-year-old black female who is 1-day post-op following a left radical
mastectomy. During morning rounds, the off-going nurse shares with you during bedside
report that the patient has been experiencing increased discomfort in her back throughout
the night & has required frequent help with repositioning. She states that the patient was
medicated for pain approximately 2 hours ago but is voicing little relief & states that you
might want to mention that to the doctor when he rounds later this morning. With the
patient appearing to be in no visible distress, you proceed on to the next patient’s room for
report.
Approximately 1 hour later, you return to Ms. Jackson’s room with her morning pills &
find her slumped over the bedside stand in tears. The patient states, “I don’t know what is
wrong, I don’t feel right. My back hurts & I’m just so tired. What is wrong with me?” The
patient refuses to take her medications at this time stating that she is starting to feel sick to
her stomach.
Just then the nursing assistant comes into the patient’s room to record Ms. Jackson’s vital
signs, you take this opportunity to quickly research the patient’s medication record to
determine if she has a medication ordered for nausea. Upon return, the nursing assistant
hands you the following vital signs: T 37, R 18, & BP 132/54, but states she couldn’t get the
patient’s pulse because “it is all over the place.”
Please address the following questions related to the scenario.
1. What do you suspect is the cause of the patient’s symptoms?
2. Describe the course of action that you will take to confirm this suspicion & prevent
further decline.
3. What further assessments, lab values, & tests will likely be ordered for this patient
& how often? If testing is to be completed more than once, please explain the rationale for
doing so.
4. While you are caring for this patient, how will you ensure that the needs of your
other patients are being met?
What do you suspect is the cause of the patient’s symptoms?
The greatest risk of atrial fibrillation is a thromboembolism (Hardin & Steele, 2008 p.29)
& because of Esther’s pain, nausea, the inability to obtain an accurate pulse, & that fact
she is post op, my first thought is Atrial Fibrillation although an MI can not be ruled out
at this time & should always be suspected until it is officially ruled out as a possibility.
Describe the course of action that you will take to confirm this suspicion &
prevent further decline
Besides notifying the Doctor to update, I would immediately place Esther on 2 liters of
O2 & obtain a 12 lead EKG, this is important to see what rhythm Esther is in & if there
are any concerning changes from her last (hopefully there is a baseline). If A-fib is
confirmed on the EKG I would assume because of her symptoms she is not in a
controlled rate so I would attach her to a cardiac monitor & push Lopressor or Cardizem
per MD orders. In the mean time it would be important to make sure a transfer is in
place to move Esther to a higher level of care.
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What further assessments, lab values, & tests will likely be ordered for this
patient & how often? If testing is to be completed more than once, please explain
the rationale for doing so.
STAT Cardiac enzymes every 6 hours x 3, BMP & mag level, CBC, Cardiac enzymes
can be an important indicator if she is having an MI or any demand ischemia (Jarvis
2016 p493 table 19-2). Cardiac enzymes must be a series because the elevation may
not occur immediately. Potassium & magnesium levels are important to know in case of
any abnormalities they can have an effect on the function of the heart. CBC will show us
if Esther’s H&H are low especially being post surgery, this can cause demand on the
heart as well. In the mean time frequent vital signs, every 15 minutes until she is stable,
continuous telemetry monitoring & thorough cardiac assessment every 4 hours possibly
a cardiology consult. Once things are settled down & Esther is stable an
echocardiogram would be helpful to see if there has been any change in the function of
her heart & maybe a stress test.
While you are caring for this patient, how will you ensure that the needs of your
other patients are being met?
Because it is the beginning of the shift & I am just starting my assessments & morning
med pass I think calling a Rapid Response would be appropriate here. I am assuming
we are on a medical floor, so Esther is going to require a move to higher level of care to
the Telemetry unit or maybe CCU, depending on whether she should require a cardiac
drip. The Rapid Response team would allow for me to concentrate on my other patients
& give me the ability to focus on them.
References:
Jarvis, C. (2016). Physical examination & health assessment (7 th ed.). Philadelphia,
PA: Saunders.
Hardin, S. R., & Steele, J. R. (2008). Atrial Fibrillation Among Older Adults. Journal of
Gerontological Nursing, 34(7), 26-33. doi:10.3928/00989134-20080701-04
According to this week’s lecture “Assessment of any patient includes taking in & analyzing the
data about the patient’s physical status but must always include the aspects of the person that are
important to nursing” (CCN, 2014).
Mr Lei has a number of diagnosis : Imbalanced Nutrition: Less Than Body Requirement, Social
Isolation & Grieving (Dysfunctional).
Mr Lei is Vietnamese, therefore, his diet will likely reflect his heritage. I would implement a
nutritional assessment that will provide data for designing a plan of care to alleviate his
undernourishment, & establish baseline data for evaluating the effectiveness of his nutritional
care.Since food is a universal concept, I would have to ask Mr Lei to define the word; if there is
any food allergy, preference; any medication being taken(prescription or OTC); his elimination
pattern; any recent surgery or chronic illness & lab data.I would also refer Mr Lei to a nutritionist
& recommend him getting a Home Health Aide to assist in preparation of his meals.
I would expect Mr Lei’s physical exam to reflect:
dry flaky skin, dull dry hair, cracked lips, dry mucous membrane, brittle nails, pain in calves,
joint & thighs, muscle wasting & may be a little disoriented.
Hypoglycemia, elevated WBC, & low serum albumin level.
Due to the recent loss of his wife & his children moving away, Mr Lei’s psychosocial well being
has been greatly impacted. According to D’Amico, Barbarito, Donita,and Colleen (2010)
Families influence psychosocial health because they are expected to provide for physical safety
& economic needs, they also, promote adaptive & coping skills; In addition, to family, cultural
factors plays an integral part in an individual’s experience & the ways in which one responds to
stress, coping & life situations (D’Amico, Barbarito, Donita & Colleen 2010).
References
D’Amico, Barbarito, Donita, Colleen. Health & Physical Assessment in Nursing. 2nd Edition.
Pearson Learning Solutions, 2010. VitalBook file. Bookshelf.
Chamberlain College of Nursing. (2014). NR305 Health Assessment. Week 2 lesson. St. Louis,
MO: Online Publication.
Mr. Lei’s Nutritional Assessment Shonette Alexander Email this Author 9/12/2014
7:29:10 AM
Based on the information provided, Mr. Lei’s Nursing Diagnosis is:
Imbalanced Nutrition: Less than Body Requirement r/t weight loss & dehydration
The nutritional assessment for Mr. Lei shows a 12% weight loss in the last six months, & his
BMI is 17.6, which indicates moderate malnutrition (D’Amico, p.138). Mr. Lei’s dietary recall
indicates his meals aren’t appropriately balanced, he has been missing proteins in his diet since
his wife’s death, & doesn’t include fruit in his recall.
Additional information needed for Mr. Lei’s nutritional assessment are skin fold measurements,
muscle mass, glucose, & albumin blood levels. An objective physical assessment to identify
brittle and/or dull hair, skin turgor & pallor, the conjunctiva of his eyes for paleness or yellow
discoloration, dry, cracked lips, & tongue furrows (D’Amico, p.43) is also needed.
Upon assessment, it is important to consider Mr. Lei’s recent loss of his spouse & his grieving
process. Also, he may now feel alone, & have some resentment towards his children because
they have moved away, unlike Vietnamese tradition. It is important to ensure he receives the
appropriate guidance to work through his grief. Cultural factors to consider for Mr. Lei would be
to recall he may prefer a same-sex provider, & to keep on mind that in Asian cultures, lack of eye
contact is common.
References:
D’Amico, Barbarito, Donita, Colleen (2010). Health & Physical Assessment in Nursing (pp 69).
2nd Edition. Pearson Learning Solutions.
Chamberlain College of Nursing. (2014). NR305 Health Assessment. Week 2 lesson. St. Louis,
MO: Online Publication.
RE: Mr. Lei’s Nutritional AssessmentCrystal Toffton Email this Author 9/14/2014 12:43:38
PM
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