Clinical Assessment and Diagnosis †Free Samples for Students

Question: What Is The Clinical Assessment And Diagnosis? Answer: Introduction Mr. Giovanni DeBella aged seventy-two years old, who experiences the Chronic Heart Failure condition, got presented to the Emergency Department very early in the morning with complaints about the difficulties in breathing and a burning sensation feeling to suffocate. At the ward, Mr. Giovanni gets about three pillows to use on the bed to raise his head for easy breathing, but this did not help on his dyspnea condition. Furthermore, Mr. Giovanni narrates to the nurse on duty that in a couple of days now he found it challenging to move around his house minus the feeling of getting puffed(Yancy, et al., 2013). He further tells the nurse that upon showering the breathlessness increases, got problems with putting on his shoes due to the swelling of his feet and he smokes. The essay paper shall focus on the assessment of the patients important clinical manifestations and the two prioritized problems which are the impaired gas exchange and the excessive fluid volume. Clinical Assessment and Diagnosis. On assessing Mr. Giovanni, the following were the vital signs and symptoms that got noted. His body temperature was at normal range 36.9 degree Celsius, the heart beat rate of 115 per minute, the electrocardiogram was normal, the blood pressure was 118/60. Moreover, the respiratory rate was at 26 per minute, and the room air had ninety-one percent oxygen saturation. During the process of auscultation, it got noted that the patient had a widespread for the course crackles and a wheezing sound(Ponikowski, et al., 2013). The chest x-ray results show that Mr. Giovanni has got an enlarged ratio for the cardiothoracic, in his lower lobes there are white patches with the lines of Kerly B. The patient get diagnosed to have an acute manifestation of the heart failure. Impaired Gas Exchange The problem of the impaired gas exchange relates to Mr. Giovannis signs and the assessment data recorded by the nurse on duty. On admission, Mr. Giovanni narrates to the nurse that he usually experiences shortness of breath and his condition for dyspnea is unrelieved even if he uses more than two pillows to sit up while on the bed(Mentz, et al., 2014). Further, during the auscultation process, wheezing sounds are heard, and the widespread crackles got noted by the nurse. The assessment data also shows that the patient gave that he ages above 65 years old, he most likely experienced falls. Mr. Giovanni though confirms that he does find it difficult to locomote around his house freely(Yancy, et al., 2013). The assessment data believed to correctly and accurately recorded as per the professional nursing standards of practice, they clearly show that the patient does require support and prevention from falls. Based on the pathophysiology, the problem of impaired gas exchange does relate closely to the breathing difficulties and the struggle for head raised through the help of pillows to get access to fresh air. The room itself gets saturated by about 91 percent of oxygen to assist the patient in easy access to fresh air. In such circumstances of a patient experiencing the difficulties of breathing, physiologically the lungs processes of inhalation and exhalation are not in the balance(Russell, et al., 2015). It gets realized that Mr. Giovanni would easily struggle to breathe in but would fail to breathe out much quickly. Such a situation confirms the problem of the impaired gas exchange in the patient. Pathophysiologically, the nurse, should realize that Mr. Giovanni experiences difficulty in walking around his house due to the fatigue arising from the accumulation of lactic acid in his muscles(Asgar, Mack, Stone, 2015). The lactic acid also leads to the muscle cramping. The accumulation of the acid results from the process of partial anaerobic respiration which takes place in the patient due to the low amount of oxygen that get inhaled to support aerobic respiration solely. Anaerobic respiration occurs to provide the little energy and vigor for Mr. Giovanni. Due to the problem of impaired gas exchange, Mr. Giovanni would unequally breathe in and breath out, hence, the unbalanced ratio between oxygen and the carbon dioxide gases. Nursing Interventions for Impaired Gas Exchange So as to assist Mr. Giovanni, the following nursing interventions are necessary and relevant in relieving his dyspnea condition. The patients respiratory system should get closely examined and evaluated. The efficiency for the perfusion should get established(Verbrugge, et al., 2013). This gets to be necessary for the process of determining whether Mr. Giovannis respiratory ventilation system functions properly or not. As a nurse, one should examine a patients respiratory rate so as to find out what would cause shortness of breath. In the case scenario, the nurse on duty measured Mr. Giovannis respiratory rate as a way of documenting and using the assessment data in making informed decisions regarding the nursing care of the patient(Tanai Frantz, 2015). Moreover, another nursing to put in place involves the maintenance of the patients bed at an elevated angle of 90 degrees. This nursing intervention ensures that the patients head gets raised at a higher level in order to access fresh air easily to fight difficulties in breathing. When Mr. Giovanni gets admitted, the nurse provides three pillows for the patient to use. The shortness of breath has a closer relationship with the cardiovascular complications. Usually, the dyspnea condition clinically manifests the heart failure(Kupper, Bonhof, Westerhuis, Widdershoven, Denollet, 2016). Focusing on Mr. Giovanni, the identification of the dyspnea symptoms such as the respiratory complications gets associated with the pulmonary venocapillary congestion which regularly presents difficulties in breathing at night when he lies horizontally on the bed. Such happens to Mr. Giovanni because of the fluid displacement into the far interior section of the patients lungs. Such a condition prompts M r. Giovanni to sleep almost in a sitting position with the help of the three pillows provided to prevent the heart failure as a result of the pulmonary venocapillary congestion(Park, et al., 2015). Usually, the dyspnea condition increases when the patient lies horizontally on a level platform but do decrease when he sits. The sitting position to control dyspnea symptom is known as orthopnea. Mr. Giovannis physical activities such as doing exercises and walking around the house may receive nursing intervention through implementing the method of elevating his bed to reduce the functional dyspnea. Also, the dyspnea condition leads to the problem of respiratory ventilation-perfusion and the impaired gas exchange with the respiratory acidosis which impacts on the patients quality of life and physical activities such as walking and the sleeping manner(Kasai, Bradley, Friedman, Logan, 2014). The implementation of the two priority interventions mentioned herein would help to reduce both the dyspnea condition and the dysfunctional dyspnea for Mr. Giovanni. Excess Fluid Volume The problem is commonly known as the hypervolemia condition, refer to the increase in the isotonic fluid retaining which result in the ECF expansion due to the sodium content and water increase proportionately in the total body. The problem does arise from the compromising of the regulatory actions on the sodium and water which occurs in the patients with heart failure or the kidney failure and the liver failure conditions(Kitzman, et al., 2014). It got also, believed that the problem of The Excess Fluid Volume would result from the excessive consumption of the sodium containing foods, medical drugs, IV solutions or from the diagnostic dyes. Similarly, the following medical conditions might lead to the Fluid Volume Excess; the hemodialysis, the peritoneal dialysis, and the myocardial infarction(Sousa, et al., 2015). For the condition to get treated or rather controlled, the sodium content and fluid intake should get regulated. The restriction of the sodium and water consumption would offer effective treatment for the hypervolemia and ensure that the extracellular compartment gets back to normal. In the case scenario involving Mr. Giovanni, the nursing diagnosis shows that the patient has the condition of acute failure(Ambrosy, et al., 2014). Studies do substantiate that the excess fluid volume usually gets diagnosed in the patients with heart failure. The problem relates closely to Mr. Giovannis signs and the assessment data accurately recorded by the nurse who attended to the patient. The problem has got characteristics for the pulmonary crackles which are evident in Mr. Giovanni. Moreover, the problem displays the clinical manifestations for the elevated capillary pressure of the pulmonary, the dyspnea symptom and the dysfunctional dyspnea(Haykowsky, Brubaker, Morgan, Kritchevsky, Kitzman, 2013). Most of these symptoms are similar to those Mr. Giovanni tells the nurse and those that have got documented in the patient's data book. The clinical research that got conducted by different clinical experts does validate that the cardinal symptoms of the dyspnea, the orthopnea, and the pulmonary congestion, shows that characteristics for such conditions are the primary clinical indicators for the problem of the Excessive Fluid Volume. The overhead signs and clinical manifestations for Mr. Giovanni clearly depict the problem(Park H. , 2014). The clinical manifestation for dyspnea in Mr. Giovanni forms the most significant condition to validate the Excessive Fluid Volume due to its high-reliability index which got obtained during the clinical research study. Most patients show to have the dyspnea condition, approximately 94%. Nursing Interventions for Excess Fluid Volume The following nursing interventions are critical to the treatment of the hypervolemia condition in Mr. Giovanni. The nurse on duty should direct and monitor the fluid intake for Mr. Giovanni. The nurse should ensure that the patient under her/his care takes controlled amounts of water such that regimen compliance gets enhanced. Further, the fluid control should get done through the prescription of the taking of the diuretics which would assist in the process of excretion of the excessive body fluids. Another effective nursing which should get prioritized for Mr. Giovanni should involve the limiting of the sodium amount intake(Jeronymo Cruz, 2015). The amount consumed by the patient should get restricted by the nurse or the family caregivers. The sodium content needs to get regulated such that little fluid retention happens. The nurse should take charge in educating the patient and the family members or relatives on the essence of liquid restrictions and how it should get done. The n urse on duty should further disperse information and vital knowledge concerning the Excessive Fluid Volume condition to the patients and the family caregivers. For Mr. Giovannis case scenario, the critical with a very close correlation with the hypervolemia condition includes the HR which got recorded by the nurse as 115/minute, and a BP of 118/60 was also noted down in the patients record book. During the nursing interventions, the nurse on duty should monitor the BP and the HR closely since they provide evidence-based leads to the early developmental stages of the condition. For instance, if the BP increases, it would be an evident sign of the Excessive Fluid Volume condition(Butcher, Bulechek, Dochterman, Wagner, 2013). According to the measurements obtained from the assessment data, the BP seems high or rather elevated giving a clue that Mr. Giovanni has the condition and necessary restrictions on the sodium content and the fluid intake should get implemented. The nurse may choose to direct that drinks a specified number of glasses of water he should drink within a stipulated period or administer diuretics prescriptions. In most cases, the high blood pressure hinders the fluid flow from the body, hence, increased fluid retention which results to the increased fluid volume accumulation in the body. Conclusion Mr. Giovanni, aged 72 years would be suffering from heart failure condition. Based on the diagnosis, the assessment data recorded by the nurse and the signs noted are evident that the patient had two major problems. The problems include the impaired gas exchange and the Excessive Fluid Volume. The impaired gas exchange hinders the patient from breathing normally. Mr. Giovanni on admission to the emergency department, he informs the nurse attending to him that he experiences shortness of breath, dyspnea dysfunction on his physical activities such as walking around his house. He further mentions that he does smoke but the condition of breathing with difficulty has hindered his regular exercising activity. 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