NR305-10247: Health Assessment for the Practicing RN #3

NR305 Week 3 iHuman Nurse Notes Template

1. Write an SBAR note

S – Michael Granger 69 y.o. Male who came to the cardiologist’s clinic with c/o 8 lb weight gain twice, SOB twice, and BLE edema. 5’9″, 178 lbs. NKA. Total Code. V.S.S q4hr. Dx: Exacerbation of heart failure. Weigh qAM. fluid restriction of 2 litres. In bed, SCD to BLE, strict I/O. Hx: stage II right-sided heart failure diagnosed one year ago; CAD; hyperlipidemia; hypertension; MI three years ago.

B – PMH: MI x 3 years ago, CAD, hyperlipidemia, HTN, Stage II Right-Sided Heart Failure diagnosed 1 year ago.
Currently Taking: Aspirin (81 mg/day), fish oil (2.4 g/day), hydralazine (100 mg/day), metoprolol (25 mg/day), simvastatin (40 mg/day), spironolactone (25 mg/day), and valsartan (40 mg/day) are all prescribed.
Psych Hx: cohabits with a spouse. Married. Retired. occasionally drinks. presently a daily 1 ppd smoker. denies abusing drugs. No exercise and a diet high in sodium are not followed.

A – VS: 128/72 BP, 84/24 HR, RR, T98.8, and 90% SPo2.
HEENT: Head, Eyes, Ears, Nose, and Throat Examination
Respiratory: There is no cyanosis, unlabored breathing, and coarse crackles in the posterior/anterior bases.
Rhythmic and regular heartbeat. S3 heart sounds were audible near the left midclavicular line, fifth intercostal space. 3 seconds maximum. equal pulse in all four extremities. pitting edoema in BLE 2+.
Neurologically appropriate verbal, movement, and sensory for the patient; a/ox4.CN II–XII: unbroken. NO anomalies in gait.
GI: non-tender and soft. There are bowel movements in each quadrant.
Musculoskeletal: Full range of motion in each extremity. Normal muscle strength.
Skin: Scrubbed, undamaged, and dry
Labs: BNP 5.1, CXR revealed cardiomegaly and pulmonary edoema.

R – All hypertension patients should visit their doctor on a frequent basis to monitor their blood pressure and make sure their medicine is working.
Problem Statement
The patient, a 57-year-old man, has a history of hypertension as well as a family history of the condition and its complications. His physical examination is notable for his high blood pressure, lateralized PMI, and A-V nicking results.

2. Describe two priority teaching topics for Mr. Granger’s discharge plan.

a) Smoking increases a person’s risk of developing coronary heart disease, which can result in a heart attack. The primary preventable cause of death is smoking. Smoking significantly increases the strain on the heart and can cause lifelong harm. (Roger, 2021). Atherosclerosis, a buildup of fatty arteries, is brought on by smoking. The heart must work harder to pump blood because of the clogged arteries, and this added stress weakens and harms the heart muscle. Additionally, it raises your heart rate and blood pressure, putting more strain on your heart. The risk can be quickly reduced by giving up smoking. Smoking continues to increase the damage to the heart. Because the heart cannot adequately circulate blood throughout the body, there is an abundance of fluid in the lungs, foot, and other areas. Lifestyle modifications can be used to cure heart failure. There is no safe level of smoking; even one puff accelerates the effects of smoking on your entire body, especially the heart.
b) Try nicotine replacement treatment, such as over-the-counter patches, gum, and lozenges, as well as prescription nasal sprays and inhalers, if you want to stop smoking. Avoid situations like parties and stressful feelings that could act as smoking triggers. When you feel the want to smoke, tell yourself to put it off for 10 minutes and find something else to do. Keep your mouth occupied by chewing on hard candies, celery, or sugar-free gum to ward off cravings. One is not enough because you will likely want to consume two, three, and four more afterward. Make use of your family, friends, or a support group. Resources include 1-800-QUIT-NOW and Stop Smoking Forever leaflet from the AHA.
Using less salt in your food is crucial. Your body’s water content may increase if you consume too much salt or drink too much liquid, which will make your heart work harder. This could make your heart failure worse, but eating right will help with some of the symptoms. If you crave salt, you can gradually train your taste buds to enjoy meals that are lower in salt by learning to like them. Salt can mask flavours, therefore removing it might bring them out. Since fresh fruits and vegetables only contain a little amount of salt, choose a lot of them. Pick salt-free foods like yoghurt, milk, eggs, fresh meats, poultry, and fish. Plain rice, spaghetti, and muesli are nutritious low-sodium options; season with herbs and spices rather than salty or sodium-containing concoctions. You can use lemon juice, freshly ground pepper, and salt-free blends, among other things. Be mindful, check the food labels on packaged foods, and try to choose goods with 350 milligrams or less of sodium. Remove the salt shaker off the table if you are dining out.

3. what findings in your iHuman assessment led you select these discharge teaching topics?

The discharge teaching topics were based on the following findings: Heart failure: What is it? What symptoms and indicators are present in heart failure? What are the heart failure risk factors? What side effects might heart failure cause? How to control heart failure by lifestyle modifications. How to take drugs for heart failure. When should someone with heart failure seek medical help? In general, heart failure, a chronic disorder in which the heart muscle is weak and unable to pump blood as effectively as it should, affects the patient. Numerous symptoms, such as shortness of breath, exhaustion, and swelling in the legs and feet, may result from this. Although heart failure is a serious condition, it is treatable with medication and a change in lifestyle.

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