4.8.3: What Should the Nurse Do?

What Should the Nurse Do?

Mrs. Johnson, a 65-year-old female patient, presents to the emergency department with complaints of shortness of breath and chest pain. She has a history of hypertension and hyperlipidemia. On examination, Mrs. Johnson appears anxious, with elevated blood pressure (160/90 mm Hg), increased heart rate (110 bpm), and labored breathing. Her oxygen saturation is 88 percent on room air. Mrs. Johnson reports that the shortness of breath and chest pain began suddenly about two hours ago while she was at home. She describes the chest pain as a crushing sensation in the center of her chest that radiates to her left arm. She has not experienced this type of pain before and notes that it is not alleviated by rest.

Further questioning reveals that Mrs. Johnson has a family history of coronary artery disease, with her father experiencing a myocardial infarction in his 60s. She admits to occasionally missing her hypertension medication due to forgetfulness. Additionally, she reports a recent increase in stress due to caring for an ailing spouse.

1 .

The nurse determines that Mrs. Johnson’s medical history of hypertension and hyperlipidemia are related to her current presentation. Which step of the CJMM is the nurse in?

2 .

The nurse applies supplemental oxygen and performs an electrocardiogram (ECG), per the provider’s orders. Which step of the CJMM is the nurse in?

Mr. Lee, a 50-year-old male, arrives at the clinic with complaints of chronic fatigue, unexplained weight loss, and persistent abdominal pain. He has a history of type 2 diabetes and hypertension. On examination, Mr. Lee appears visibly fatigued, with a blood pressure of 140/90 mm Hg, a heart rate of 95 bpm, and a body mass index (BMI) indicating recent weight loss.

As the nursing team delves deeper into Mr. Lee's case, additional information unfolds. Mr. Lee reports that the chronic fatigue has been progressively worsening over the past few months, significantly affecting his daily activities and overall quality of life. His unexplained weight loss, approximately 15 lbs (6.8 kg) over the last three months, has been unintentional and accompanied by a loss of appetite. The persistent abdominal pain, which he describes as a dull ache that intensifies after meals, is localized in the upper abdomen.

Further exploration of Mr. Lee's medical history reveals suboptimal diabetes management, with inconsistent blood glucose monitoring and irregular medication adherence. Additionally, he reports occasional episodes of dizziness and blurry vision, which he attributes to his hypertension medication.

3 .

Based on the information provided and using the CJMM, what cues should the nurse recognize as potentially being relevant to the patient’s condition?

4 .

Based on the recognized cues, what further information should the nurse gather to analyze the cues?