(SOLVED) Identify priority assessment findings that require immediate follow-up by the nurse.

Question

Nursing assessment reveals the following:

radial pulse too rapid to count, apical pulse 160 beats per minute and irregular

BP 168/98, RR 24, and oral temp 99.4°F (37.4°C), SpO₂ was 95% on room air.

EKG shows atrial fibrillation with rapid ventricular response of 164.

Skin is warm, flushed, and dry.

Reports a headache, and falls asleep during the interview, with a decreased level of consciousness.

Lower legs have 1+ edema bilaterally. States her last bowel movement was 2 days ago.

1) Identify priority assessment findings that require immediate follow-up by the nurse.

2) Explain how atrial fibrillation has contributed to the patient’s current condition.

3) What nursing actions do you expect the nurse to perform? Include medical orders and medication administration?

4) What are the expected outcomes from the nursing actions listed in question 3?

Expert solution paper

answer 1: priority assessment is palpitations, shortness of breath, and weakness

in vital sign -

• radial pulse are too rapid, apical pulse is 160 beats/minute and also irregular
• BP is 168/98, RR is 24 beat per min, and oral temp is 99.4°F (37.4°C), SpO₂ is 95%.
• assessment shoud be made on -Skin i.e. warm, flushed, and dry
• there is presence of
• headache
• falls asleep
• decreased level of consciousness.
• Lower legs have 1+ edema.
• constipation.

answer2:

1. damage to the heart may caused by other conditions like high blood pressure and coronary heart disease
2. firstly When the heart’s tissue or electrical signaling are damage
3. it will lead to regular pumping of the heart muscle.
4. which will make the heart rate fast and irregular and also show the other symptoms.

answer 3: nursing actions of the nurse at the time of atrial fibrilation are as followes-

nurse should be pripare emergency trolly

assess the leve of consciousness

provide rest to the patient by providing comfortable position

assessment of vital sign.

administer spo2 if needed

condition should be explained immidiately to the doctors.

reset the treatment aims- manage the heart's rhythm, it shoud be normal.

ecg should be performed to detect abnormal electrical signals

provide medication as per doctors order like-.

Medication

• Anti-arrhythmic drugs- it shoud be given orally or intravenously to restore normal functions of the sinus node example of medication are-

1. Quinidine

2. Dofetilide

3. Propafenone

• Anticoagulants- it will help To prevent blood clot and stroke.
  example Warfarin

nurse should prepare the articles of Medical procedures like -

1. Electrical cardioversion
2. · Catheter ablation ·
3. Atrioventricular (AV) node ablation ·
4. Left atrial appendage closure
5. · Maze procedure

answer 4 : expected nursing outcomes from the nursing actions are given below-

outcomes are-

nurse should be pripare emergency trolly - it will help to save the life of patient in the emeergency situation

assess the leve of consciousness- to assess the which action is next going to perform

provide rest to the patient by providing comfortable position- shortness of the breath can be managed

assessment of vital sign - o2 can be administerd

administer spo2 if needed

condition should be explained immidiately to the doctors - for proper management

ecg should be performed -to detect abnormal electrical signals

provide medication as per doctors order like-.

Medication

• Anti-arrhythmic drugs- it shoud be given orally or intravenously to restore normal functions of the sinus node example of medication are-

• Anticoagulants- it will help To prevent blood clot and stroke.
  example Warfarin

nurse should prepare the articles of Medical procedures like -

1. Electrical cardioversion
2. · Catheter ablation ·
3. Atrioventricular (AV) node ablation ·
4. Left atrial appendage closure
5. · Maze procedure