1. Medical History: CHF, obesity, hypertension concerning

1. Medical History: CHF, obesity, hypertension concerning a patient who has pulmonary embolism- Explain the significance of each of the components of the medical history 2. Obiective Data General Appearance: Giles looks apprehensive. He is sitting up in bed and is clean and well groomed. His spouse is at bedside. He complains of shortness of breath and chest discomfort. Temp: 36.8°C (98.24°F) BP:120/80 mmHg MAP 93 HR: 118 bpm RR: 30 Sp02: 90% on RA NEURO: Alert and oriented to person/place/time/situation. GCS 15. PERRLA. Anxious. CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable and weak x4 at +1. No edema. No murmur RESP: Lung sounds clear in RUL, LUL, RML and basilar crackles in RLL and LLL. No stridor. Respirations are symmetrical and labored. GI: Abdomen obese. Soft, non-tender. NABS ×4. Last BM was today. Negative for nausea and vomiting. GU: Voids painlessly and without hesitation. Clear, yellow urine. UA normal. Musculoskeletal: Moves all extremities with no overt deficits. Ambulates unassisted but is slow paced. Equal grip strength bilaterally. Integumentary: Skin is warm, dry, and intact. No bruises or wounds noted. Psychosocial: Broad affect, apprehensive. Wife at bedside for support. Discuss the signficance of the general appearance, vital signs, and one assessment finding for each of the systems. 3. You are preparing Giles for discharge home. He received TPA therapy and was in ICU for 10 days. He was extubated and has been tolerating room air. His vital signs are back to baseline. He is eating well and ambulates independently. He is going home with his wife and they have set up home health and laboratory appointments tC monitor his INR levels. He is scheduled to see his PCP in 5 days. The following are new or adjusted prescription medications: Medication Last dose taker Coreg 3.125 mg BID 0800 _LaSIX 20 mg BID 0900 Coumadin (warfarin) 5 mg daily. 1700 yesterday What instructions will be included for him at discharge? Include five components of the discharge education that will be provided with rationales for each. SCIENCE HEALTH SCIENCE NURSING NUR NUR258

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