Part 1: Patient and Diagnosis
Describe your patient and diagnosis in the specialty area for your case study. (Note: Do not include any identifiable information.)
Patient History and Presentation
Diagnosis: A-fib RVR and CHF exacerbation
Co-Morbidities: severe obesity, CHF, ESRD on HD, A-fib on eliquis, HTN, HLD, OSA, COPD
Patient presentation (clinical findings):
History of present illness
Chief complaint: sob, palpitations, and headache
2–3 differential diagnoses
Pathophysiology of primary diagnosis: Describe common causes for changes on the cellular level and how these changes result in commonly noted clinical manifestations. Use the Learning Resources and/or the best available evidence from current literature to support your primary diagnosis.
Identify two prescribed drugs for this patient that are commonly used to treat the primary disorder. For each, outline the following:
Mechanism of action
Common adverse effects/side effects
Individualized considerations that take into account the age and condition of this patient
Use the Learning Resources and/or the best available evidence from current literature to support your identified drug choice.
Relevant diagnostic studies:
Identify at least one diagnostic test and the rationale for the order and explanation of the result.
Identify at least two relevant laboratory tests, the rationale for the order, and the explanation for the result in this patient.
Identify the major long-term nursing goal for treatment of this patient as well as two short-term nursing treatment goals.
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