NURS3001-Actual and Potential Nursing Concerns for Patient – Nursing Assignment Help

Assignment Task

Task 

List the actual and potential nursing concerns for this patient

Actual concerns are:

•  Acute pain
•  Shortness of breath(SOB)
•  Increased heart rate(Wheezing) 
•  Infective tissue perfusion 
•  Decreased SPO2
•  Decreased BP

Potential concerns are:

•  Hypoxemia
•  Infection
•  Stroke
•  Fever 
•  Indigestion 
•  Abnormal heart rhythms

Provide a rationale/reason for each of these nursing concerns

Actual concerns rationale:
Acute pain: may result in the current scenario due to obstruction of the coronary artery supplying the heart leading to less blood supply to the tissue. It can also radiate to arm (Ackley, 2020). Mr Turner fell from the toilet and was complaining pain in his chest and right arm, which needed to be care of by nurse . Also it’s found to be associated with change in blood pressure, disturbance in relaxation after surgery, pulse rate .

Shortness of breath(SOB):  SOB is related to decreased oxygen supply to the patient, with an urge of increase oxygen need leading to shortening of breath. SOB is noticed in the present case to be care of by nurse. 

Increased heart rate(Wheezing): it occurs due to decrease in the supply of the oxygen thus increasing the demand which further increases the heart rate and respiratory rate as well. Prior to surgery HR was 75, RR: 16 which after surgery changed to RR: 24 and HR:125. This results in tachycardia. 

Ineffective Tissue Perfusion: results due to obstruction in the blood inflow to the heart due to spas of the vessels, or formation of thrombus (Ackley, 2020).  

Decreased SPO2: Oxygen saturation levels also provide a measure of gas exchange and perfusion of the tissue. It helps to measure respiration working sufficiently or not. Rationale behind is due to abnormal functioning of the heart pump or oxygen supply to the heart leading to breathing problem. Also difficulty in breathing can occurs due to thrombus formation.  

Decreased BP: BP is normally found high but if the patient is suffering from cardiogenic shock, decrease in blood pressure occurs leading to hypotension.  

Potential concerns rationale: 
Hypoxemia: can affect other organ or reverse. In case of acute MI, it leads to failure of heart syndrome which occurs due to blockage of non-active pulmonary supply which leads to hypoxemia. This further causes impairment of the lung function and development of disease. 
Infection: The surgical sites can become infected after the surgery. It can be checked by seeing the surgery site for redness, change in colour and temperature. An increase in temperature, tachycardia and rigors can be found associated with it. 
Stroke: occurs due to thrombus formation in the heart valves.  
Fever: can also be found at starting of MI. later on after few days, a slow increase in temperature can be seen.   
Indigestion:  Initiated by onset of the sympathetic nerve system of brain (Herdman, 2021) knowledge insufficiency in performing self-care post-MI. it can be seen in the following cases –

1. a) In relation to the care giving individual (family or other): mostly older peoples or severely ill patients are dependent on other for care giving, so they themselves are not aware of this knowledge to self-care after surgery for acute MI.
2. b) Accessibility to learn and perform it: due to lack of cooperativeness for learning the education given by nurses to them.
3. c) Racial differences: due to change in culture, they fail to learn the process (Mosleh S.M, 2017). 

Abnormal heart rhythms: ventricular arrhythmia can be found in acute anterior MI cases.  Patient found with shortness of breath, chest pain, discomfort and syncope. It may be benign or can be life threatening. 

List a minimum of 4 interventions that need to be instigated for the remainder of your shift
1. To  treat acute chest discomfort and relieve symptoms, use oxygen in conjunction with medication therapy. Encourage bed rest with the backrest elevated  to reduce chest pain, dyspnoea and oxygen deficiency (Gulanick, M, 2022). 
2. Encourage frequent changes of position to keep fluid from building up in the lungs bases (Gulanick, M, 2022).
3. Monitor tissue perfusion by checking skin temperature and peripheral pulses periodically. Provide advice in a simple and reassuring manner (Reed GW,2017).
4. Evaluate the variation of abnormal heart sounds, pain in the chest, decrease cardiac output, respiratory rate, heart rate, redness of skin, labs for patient (Gulanick, M, 2022).   

Provide a rationale/reason for each of these interventions 

1. For acute chest pain: 

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