Case Study Analysis- Case of Jane

Subjective

Objective

Objective

The temperature was 98.6°F.

Heart rate: 94 (erratic), 20 respirations: 125/80 blood pressure, 215 pounds in weight

Additional Focused Assessments:

1.      Listening for abnormalities or murmurs in the heart’s noises

2.      Evaluation of lung sounds and identification of respiratory distress

3.      Examining the limbs for peripheral vascular disease symptoms and edema

4.      Evaluation of coping strategies, triggers, and anxiety levels

Critical Thinking

·         Respiratory distress and an irregular pulse could be signs of respiratory or cardiovascular problems.

·         Edema and weight increase point to fluid retention, which may be connected to an aggravation of heart failure.

·         Both physiological and psychological reasons may be the cause of anxiety, exhaustion, and weakness.

Assessment

Problems Identified:

·         Cardiovascular problems: Arrhythmias or heart failure that may worsen.

·         Possible pulmonary congestion or respiratory discomfort are examples of respiratory issues.

·         Psychological distress: Difficulties coping and heightened anxiety.

Nursing Diagnosis

1.      Impaired gas exchange associated with pulmonary congestion as shown by irregular pulse, auscultation findings of crackles in the lung bases, and dyspnea

2.      Anxiety related to fear of death and financial worries evidenced by her stated reluctance to seek medical attention, her request for prayers, and her justification for avoiding hospitalization: financial difficulties.

3.      Activity intolerance associated with weakness and exhaustion, as evidenced by the greater need for rest, trouble completing everyday tasks, and verbal reports of feeling weak and exhausted

Recommendation

1.      Jane will have a better breathing pattern at the end of the week, as shown by a respiratory rate that is within the usual range (12-20 breaths per minute).

2.      Jane will report that, in two weeks, her anxiety level has decreased from an 8 out of 10 to a 4 out of 10.

3.      Jane will be able to participate in mild activities for at least half an hour every day without feeling overly tired after a month.

Likely Interventions

·         Use relaxation methods to assist the patient in regulating her anxiety better and developing coping mechanisms, such as guided imagery and deep breathing exercises. Research backs up the usefulness of relaxation methods for lowering anxiety and enhancing general well-being, such as guided imagery and deep breathing exercises. With the support of these approaches, Jane can learn healthier coping skills, de-stress, and control her anxiety symptoms (Toussaint et al., 2021).

·         Work with the medical professional to modify the drug regimen as necessary to regulate the heart rate and rhythm and improve cardiac health. Effective management of cardiac dysfunction or arrhythmia requires close collaboration with the healthcare practitioner, such as a cardiologist, in order to make necessary drug adjustments (Alobaida & Alrumayh, 2021). The healthcare provider might take into account adjusting Jane’s medication, such as beta-blockers or antiarrhythmics, in order to regulate her heart rate and rhythm and improve her cardiac health.

·         To control fluid retention and lessen the strain on the heart, keep an eye on fluid intake and outflow, limit sodium consumption, and take diuretics as directed. In order to treat Jane’s fluid retention and possible heart failure, fluid balance needs to be monitored and managed. Healthcare professionals can assist in managing fluid volume and lessen the strain on Jane’s heart by monitoring fluid intake and output, limiting sodium consumption, and giving prescription diuretics (Stickel et al., 2019).

·         Motivate the patient to maintain a healthy weight, participate in regular physical activity within her limits, and eat a heart-friendly diet. It is critical to encourage a heart-healthy lifestyle for Jane’s general cardiovascular well-being. According to Ghodeshwar et al. (2023), better cardiovascular results can be achieved by encouraging her to maintain a healthy weight, participate in regular physical activity as tolerated, and eat a balanced diet low in sodium and saturated fats.

References

Alobaida, M., & Alrumayh, A. (2021). Rate control strategies for atrial fibrillation. Annals of Medicine, 53(1), 682–692. https://doi.org/10.1080/07853890.2021.1930137

Ghodeshwar, G. K., Dube, A., Khobragade, D., Ghodeshwar, G. K., Dube, A., & Khobragade, D. (2023). Impact of lifestyle modifications on cardiovascular health: A narrative review. Cureus, 15(7). https://doi.org/10.7759/cureus.42616

Stickel, S., Gin-Sing, W., Wagenaar, M., & Gibbs, J. S. R. (2019). The practical management of fluid retention in adults with right heart failure due to pulmonary arterial hypertension. European Heart Journal Supplements, 21(Supplement_K), 46–53. https://doi.org/10.1093/eurheartj/suz207

Toussaint, L., Nguyen, Q. A., Roettger, C., Dixon, K., Offenbächer, M., Kohls, N., Hirsch, J., & Sirois, F. (2021). Effectiveness of progressive muscle relaxation, deep breathing, and guided imagery in promoting psychological and physiological states of relaxation. Evidence-Based Complementary and Alternative Medicine, 2021(1), 1–8. https://doi.org/10.1155/2021/5924040