[Answered]: I need a progress note pls

I need a progress note pls. Can someone please answer these for me please. Thanks in advance 1 . Enlist the abnormal findings that you got in your assessment. 2 . What diagnosis are these findings related to ? What are some of the other issues that may present for the mentioned diagnosis? SBT Guide: HLTENN 0 4 4 – Implement and monitor care for a person with chronic health conditions 3 . What are the nursing goals? 4 . What nursing actions would you recommend for the client and why? Explain using applied anatomy, pathophysiology and evidence – based practice. 5 . Discuss some things we should avoid for this client and explain this based on pathophysiology and evidence – based practice. Scenario 1 : Edna Edmunds – [ CCF , T 2 DM , Hypertension, Hypothyroid, Osteoarthritis ] Ms Edna Edmunds is 6 2 year old client with Aboriginal and Torres Strait Islander background. She is admitted with severe shortness of breath and extreme lethargy. It has been noted that she has gained 6 kg in last 2  weeks. Baseline weight was 6 2 kg and on admission o ED was 6 8 kg . She has her blood tests taken and a chest X – ray done. After analysing investigations, she is diagnosed with exacerbation of Congestive Cardiac Failure. Mr . Chok has a history of CCF , T 2 DM , Hypothyroidism and Osteoarthritis. Edna is from the local Noongar * * community. Edna lives with her grandchildren and one of them is her next of kin. Edna does family day care for her community kids. From the discussion with family and friends, it was revealed that Edna does not comply with medications and her fluid restriction. Edna enjoys fast food and smokes 6 to 1 0 cigarettes a day. She gave up alcoholism 3 years ago. Edna uses a zimmer frame at home for mobility and has joint pain almost every day. Edna says smoking helps with her pain. She has 3 falls in the last year and states that she lost balance for two of those and once she felt dizzy. Edna has an IVC on the R ) hand and has monitor leads stuck to her chest. Edna is allergic to Penicillins and develops anaphylaxis if administered. Edna was reviewed by doctors in and the following plan of care was advised till detailed review by consultant team is done. * * Trainer could change this to the local aboriginal community where the student training is conducted. Plan of care: 1 . 2 5 L Fluid restriction, Daily weight, strict fluid balance chart and daily medical review for progress. Medications Charted: – IV Frusemide 4 0 mg BD – Irbesartan 1 5 0 mg OD – Thyroxine 1 0 0 Microg OD Mane before food – Glyclazide MR 6 0 mg OD mane – Linagliptin 5 mg OD mane – Panadol Osteo 1 3 3 0 mg TDS – PRNs o Iburpofen 4 0 0 mg TDS o Salbutamol Inhaler 2 to 6 puffs 4 hourly. Do not administer if HR > 1 0 0 beats / minute . Examination findings LOC: alert and oriented GCS = 1 5 Height: 1 6 3 cm Weight: 6 8 . 2 kg Vital signs: T = 3 5 . 6 0 C , PR = 9 8 / min ( very irregular ) RR = 2 8 / min BP = 1 6 6 / 7 2 mm of Hg ( usual SBP of client is 1 3 0 s ) SaO 2 = 9 2 % room air Random Blood glucose level = 1 2 . 8 mg / dL Observation: patient peripheries oedematous / bilateral pedal oedema. No pressure injuries present. Skin on lower limbs is shiny and fragile. Noticed that patient nails are grown and hygiene not kept. SBT Guide: HLTENN 0 4 4 – Implement and monitor care for a person with chronic health conditions HLT 5 4 1 2 1 Diploma of Nursing Session Plan Legal entity: Health Careers International Pty Ltd | ABN: 5 9 1 0 6 8 0 0 9 4 4 |  Auscultation: Bibasilar crackles. Air entry bilaterally equal on upper lobes. Bowel sounds present. Palpation: no abdominal tenderness, Peripheries cold Investigations: Chest XRAY = bibasilar consolidation Complete blood count shows the following WBC = 2 3 x 1 0 9 cells / L [ normal = 4 . 5 – 1 1 x 1 0 9 cells / L ] RBC = 3 . 5 x 1 0 1 2 per Litre [ normal = 4 . 1 – 5 . 1 x 1 0 1 2 cells / L ] HB = 1 1 3 g / L [ normal: 1 2 3 – 1 5 3 g / L ] Hematocrit = 0 . 7 6 7 g / L [ normal: 0 . 3 7 to 0 . 4 4 g / L ]  S . K + = 5 . 8 mmol / l S . Na + = 1 2 8 mmol / l S . Ca 2 + = 1 . 8 3 mmol / l ( corrected ) S . Mg 2 + = 0 . 7 6 mmol / l Pro – BNP = 1 0 8 4 pg / mL [ normal for 0 – 7 4 year = < 1 2 5 pg / mL , for patients aged above 7 5 years = < 4 5 0 pg / mL ] ( patients Pro - BNP test a year ago the value