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Female

75 years of age

Crescendo TIA

1.

a. Assess baseline vitals (blood pressure, heart rate, oxygen saturation, and respiration). Rationale: Baseline data assists in evaluating any changes and helps determine interventions needed. (Ackley. 188)

b. Closely monitor fluid intake, including IV lines. Maintain fluid restriction if ordered. Rationale: Fluid restriction can enhance volume management. Too much fluid may overload poorly functioning ventricles and cause inadequate cardiac output. (Ackley. 189)

c. Teach 3 symptoms of decreased cardiac output (chest pain, dyspnea, and fatigue) and the needs to report them right away. Rationale: Early detection of symptoms of inadequate cardiac output will increase survival rate. (Ackley. 188)

d. Collaborate with nutritionist to maintain a low sodium diet. Rationale: Excess sodium can contribute to elevation of blood pressure and increase risk for heart failure. (Ackley. 189)

2.

a. Assess skin turgor on forehead or axilla, color, temperature, and peripheral pulses every hour. Rationale: Geriatric patients have normal age-related decrease in skin turgor; using the forarm/hand is not effective. Decrease in fluid volume will cause cold, clammy skin with weak-thready peripheral pulses. (Ackley. 389)

b. Monitor fluid intake and output every 4 hours (or every hour if unstable) and recognize that input and output is an accurate indicator to fluid imbalance. Rationale: A urine output of less than 0.5ml/kg/hr is considered oliguria and increases the patients risk of kidney injury. (Ackley. 389)

c. Teach patient and family how to monitor adequate input (2000ml/day) and output in the home (use of urinal or hat). Rationale: Proper knowledge of input and output monitoring will help with early detection and correction of a fluid imbalance. (Ackley. 389)

d. Collaborate with physician to have antidiarrheals and antiemetics prescribed. Rationale: Stopping the loss of fluid via vomit or diarrhea will help retain more fluid and decrease fluid imbalance. (Ackley. 390)

3.

a. Assess baseline vitals (blood pressure, heart rate, oxygenation, and respiration). Rationale: Baseline vitals assists in evaluating any changes and helps determine proper interventions. Decrease in oxygenation, respiration, and/or cardiac output will increase risk of inadequate cerebral tissue perfusion. Hypertension is a major risk factor for hemorrhagic or ischemic stroke. (Ackley. 209)

b. Monitor level of consciousness and orientation. Rationale: Ineffective cerebral issue perfusion will cause acute confusion. Patient may be alert but not orientated to person, place, time, or situation. (Ackley. 207)

c. Teach patient warning signs of stroke using the FAST method (facial droop, arm drift, speech slurred, time symptoms started). Rationale: Using the acronym FAST helps patients remember vital signs of a stroke. Teaching them to call immediately activates early CT and possible administration of thrombolytics if within the 3 hour window. (Ackley. 208)

d. Collaborate with physician to have a cardiac monitor and EKG and antiarrhythmics medication ordered. Rationale: Atrial fibrillation increases risk of TIA and ischemic stroke. (Ackley.207)

NURSING DIAGNOSES:

RESULTS IN

EXPECTED OUTCOMES:

1. Decreased cardiac output r/t alteration in heart rate and rhythm aeb ecg change and fatigue.

2. Deficient fluid volume r/t active fluid loss aeb decrease urine output, dry skin, thirst and liquid stool.

3. Risk for ineffective cerebral tissue perfusion aeb

atrial fibrillation and hypertension.

LEADS TO

LABS AND DIAGNOSTICS STUDIES:

  • CT Head or Brain w/o contrast
  • Ultra sound Carotid Duplex Bilat
  • EEG
  • WBC: 6.5
  • Neutrophils: 76.3%
  • RBC: 4.83
  • Hgb: 14.7
  • Hct: 43.4
  • Platlet: 261

SUBJECTIVE DATA:

1. Client will report no symptoms of decreased cardiac output (chest pain, fatigue, and dyspnea) before discharge.

2. Client will demonstrate maintaing fluid intake of 2,000-3,000 ml daily before discharge.

3. Client will demonstrate adequate cardiac output aeb blood pressure, pulse rate and rhythm within normal range for client before discharge.

  • PT: 16.5
  • INR: 1.36
  • PTT: 36
  • Na+: 131
  • Ch: 95
  • Blood sugar: 96

LEADS TO

  • Client states, "I feel, for my age, I am doing extremely well".
  • Client states she had diarrhea for 2 days.
  • Client states she has dry skin frequently and pruritis.
  • Client reports no pain.
  • Client states she has seasonal allergies year round.
  • Client states, "I get winded climbing up the stairs and I didn't use to before." She further stated she has shortness of breath on exertion.
  • Client reports her father had a pace maker due to irregular heart rate.
  • Client states she has headaches, dizziness, and tingling on occasion.
  • Client states she lives alone and performs ADL's on her own.

CONCURRENT MEDICAL HISTORY:

WAYS TO HELP RESOLVE ETIOLOGY

LEADS TO

  • Unspecified atrial fibrillation
  • Essential hypertension
  • Migraine
  • Obesity
  • TIA

RESOLVE OR REVISE

MEDICATIONS:

OBJECTIVE DATA:

  • Apixaban 5 mg, PO BID
  • Lipitor 10 mg, PO Bedtime
  • Lisinopril 20 mg, PO qDay
  • Lopressor 50 mg, PO q12h

INTERVENTIONS:

  • Weight: 71.9 kg. height: 5ft 2inch. BMI: 29.
  • Admission vitals: T 98.5 F, P 90 bpm, R 16, BP 159/99.
  • Latest vitals: T 97.6 F, P 96 bpm, R 18, BP 146/94.
  • Skin color is pink with no open lesions.
  • Skin is warm, dry, and smooth even surface, it is uniformly thin with no edema.
  • Mobility and turgor are <3 seconds, with a capillary refill of <3 seconds.
  • Lungs are clear with no adventitous sounds bilaterally in all lobes. Respirations are a rate of 18 per minute.
  • Heart rate is 98 apical with an irregular rate and rhythm. No murmurs noted.
  • Braden scale score is 22; no risk for pressure ulcers.
  • LOC x4 with coherent, relevant speech.

LEADS YOU TO DEVELOPE

EVALUATION:

1. Outcome met, client reported no symptoms of chest pain, fatigue, or dyspnea before discharge. Discontinue outcome.

2. Outcome met, client maintained 2,000 ml intake every day in hospital. Discontinue outcome.

3. Outcome partially met. Clients blood pressure was within normal parameters; however, pulse rate was not in range for client (98 pulse = higher than clients normal). Continue outcome and interventions.

WAYS TO RESOLVE

Clinical Concept Map

KATIE FLENNA

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