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Concept Map: COPD, Pneumonia, UTI

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on 2 March 2015

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Transcript of Concept Map: COPD, Pneumonia, UTI

Calcium Carbonate oral 2xday
Carvedilol oral 2xday
Citalopran hydrobromide oral 1 tab daily
Clonidine HCl oral 3xday
ducosate clacium oral 2xday
lasix oral 2xday
advair diskus inhalation
duoneb inhalation
milk of mag oral
nitrostate sublingual

VS at time of care: T 98.9, P 120, RR 23 , BP 165/85 O2 99% on CPAP, Weight 81.6 Kg, Height 64 in. BMI 30.9 Pain 5/10
VS on admission: T 99, P 101, RR 26, BP 168/89 O2 83% on room air
Head: Hair clean and dry. No parasites, wounds or lesions noted on scalp. Facial skin intact and dry, no scarring noted. No open wounds noted.
Eyes: Pupils equal, round and reactive to light. No redness or swelling of eyes. No scleral icterus
Cardiovascular: S1S2 auscultated, no abnormal heart sounds noted. Cap refill >3 sec to toes bilaterally. Radial and pedal pulses palpable bilat.
RR 23, down from RR of 26 on admission
RML crackles
, 99% O2 on CPAP. Moderate respiratory distress, retractions, accessory muscle use, expiratory bilateral wheezes diffusely.
Gastro-intestinal and Genito-urinary: Abdomen soft, nontender. Active bowel sounds heard in all four quadrants. 16 fr temperature foley catheter, amber colored urine noted, sediment noted
Skin: Clean, dry and intact. No signs of infection or open wounds. Skin turgor assessed on sternum. Tenting noted. IV in L AC 18 g. IV flushed, patent. Second IV in right forearm with 20g angiocath. IV flushed, patent.
Neuro: Glascow Coma Scale 12: eyes open to voice (3), best verbal response is inappropriate speech (3), best motor response, obeys commands (6).
Musculoskeletal: Unable to assess gate or grips/pushes/pulls due to
decreased LOC
. Patient immobile at this time.
Socioeconomic Factors
Patient is a resident at Sierra Blanca.
Socioeconomic assessment could not be obtained due to patient's decreased LOC.
Past Medical History
Date of birth: 03/01/1925
89-year-old female
Hospital Admission: 01/21/15
Assessment: 01/21/15
Admitted for: COPD exacerbation, bacterial pneumonia and acute UTI
Code Status – DNR
Allergies - NKA
Chief Complaint - dyspnea, LOC changes
Pathophysiology of this Patient's Symptoms
Physical signs of pneumonia
Decreased LOC
Delirium (in elderly pts)
Clinical Manifestations
X-ray infiltrates
Positive bacterial sputum culture
Laboratory/Diagnosis Tests


WBC 14.5 High
RBC 4.09 Low
Hemoglobin 11.3 Low
Hematocrit 35.4 Low
MCV 87 Normal
MCH 28 Normal
MCHC 32.6 Normal
NRBC 0 Normal
Platelets 184 Normal
Absolute Neutrophils 13.7 High
lymph 0.3 Normal
Mono 0.3
Eosin 0.1
Baso 0.0
percent Neut 93 High

EKG: Ordered
BIPAP: Ordered

Sodium 145 Normal
Potassium 4.3 Normal
Chloride 103 Normal
CO2 30.0 Normal
Anion Gap 16 High-due to High PaCO2
Glucose 136 High
BUN 90 High
Creatinine 2.3 High
Calcium 9.0 Normal
GFR 20

INR 1.1 Normal

Triponin STAT: 0.01 Normal

Influenza A: Negative
Influenza B: Negative

Lactate Arterial: 1.61 High

Chest X-ray: Infiltrate in the RUP and RML

CT Head: No acute changes.

-IV Saline Lock
-Continuous SVN: 10mg Albuterol with 2mg Atrovent with 1mg Pulmicort, over 40-50min
-Methylprednisol one Sodium Succ IV 125mg (Solumedrol)
-Magnesium Sulfate IV: initial bolus 1gm/100mL HIGH ALERT!
-Vancomycin IV 1 gm/250 mL (Mix in NS 250mL)
-Piperacillin-Tazobactam IV (premixed IV bag 3.375 gm/50mL) 3.375mg
-Nitroglycerin Paste Topical 1gm/inch (Nitro-bid ointment)
-Morphine IV 4mg HIGH ALERT!
-Furosemide IV 40mg (Lasix)
-Rocephin Injection, 1gm daily for UTI, next 9 days
Potassium Chloride ER Oral 20 meq daily
Symbicort Inhalation aerosol 160-4.5 mcg/act 1 puff 2xday
Zyrtec Allergy Oral (10mg tab) 1 tab daily
Phenergen oral 25mg PRG
Nitrostat Sublingual 0.4mg as needed
Known allergies: None
Nursing Diagnosis #1 Impaired gas exchange r/t fluid filled alveoli as evidenced by dyspnea

Nursing Diagnosis #2
Ineffective Airway Clearance r/t increased sputum production in response to respiratory infection as evidenced by change in respiratory status, sputum.

Nursing Diagnosis #3 Anxiety
r/t respiratory distress as evidenced by tachypnea and tachycardia.

Nursing Diagnosis #4
Impaired Urinary Elimination r/t urgency and frequency, UTI as evidenced by elevated Leukocyte Esterase 3+, urinating every 30 min.

Nursing Diagnosis #5 Deficient Knowledge r/t recent diagnosis as evidenced by development of complications

Gulanick, M., & Myers, J. L. (2011). Chronic pain. In R. Carter, & D. Dedeke (Eds.), Nursing care plans: diagnoses, interventions, and outcomes (7th ed., pp. 155-158). St. Louis, MO: Elsevier Mosby.
Harkreader, H., Hogan, M., & Thobaben, M. (2007). Health protection: risk for infection. In S. R. Epstein, & M. Broeker (Eds.), Fundamentals of nursing: caring and clinical judgment (3rd ed., pp. 496-535). St. Louis, MO: Saunders Elsevier.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). . In J. Rodenberger, & M. K. Ziegler (Eds.), Davis’s drug guide for nurses (13th ed., pp. 29-1379). Philadelphia, PA: F.A. Davis Co.
Van Leeuwen, A. M., Kranpitz, T. R., & Smith, L. (2006). Complete blood count. In L. B. Dietch, & I. H. Richman (Eds.), Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications (2nd ed., pp. 413-420). Philadelphia, PA: F.A. Davis Co.
Nursing Diagnosis

Hx of cystitis, pneumonia, angina, HTN, asthma, pleural effusion, hyperkalemia, CHF, heart disease, CVA, UTI, fall, TIA, depression and diabetes mellitus.
Medication Hx
Inpatient Meds
Concept map: COPD, Pneumonia, UTI
Short Term
Low O2
Decreased LOC
Long Term
Pleural Effusion
Ventilatory Failure
Hypoxemic Respiratory Failure
Patient presented with decreased LOC, shortness of breath and dyspnea
Patient presented with tachypnea.
Oxygen level is 83 % on room air.

89 year old woman with hx of COPD -> weakened pulmonary system -> bacterial infiltrates -> pneumonia -> decreased LOC
of COPD, pneumonia and UTI
COPD, also known as Chronic Obstructive Lung Disease is a type of obstructive lung disease characterized by chronically poor airflow. An exacerbation of COPD may be triggered by a bacterial infection. Airway inflammation is increased during the exacerbation resulting in increased hyperinflation, reduced expiratory air flow and worsening of gas transfer. The alveoli fill with fluid, worsening the exacerbation.

A urinary tract infection (UTI) is most commonly caused by a bacterial infection that enters the urethra. From there, it infects the bladder (cystitis).
1. Anxiety is known to intensify physical symptoms.
2. Clients experiences less anxiety and emotional distress and have increased coping skills because they know what to expect.
3. Patient Safety.
4. Anxiety can be reduced by using relaxation techniques.
5. Decrease dyspnea and reduce anxiety.
1. Assess client for signs and symptoms of fear and anxiety (e.g. verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness, diaphoresis, elevated blood pressure, tachycardia
2. Maintain a calm, supportive, confident manner when interacting with client
3. Do not leave client alone during period of acute respiratory distress
4. Instruct client in relaxation techniques and encourage participation
5. Administer oxygen and position patient in a High Fowler's position.
1. In initial hypoxia, BP, HR and RR all rise.
2. Hypoxia results from increased dead space that reduces effective gas exchange. s/s tachycardia, restlessness, diaphoresis, HA, lethargy and skin color changes.
3. Cook, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic.
4. Increased restlessness, confusion and/or irritability are early indicators of insufficient oxygenation of the brain and requires further intervention.
5. Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be at 90% or greater. ABG's provide information about developing hypoxemia and respiratory acidosis.
1. Monitor vital signs, noting any changes
2. Assess for s/s of hypoxia
3. Assess skin, nail beds and mucous membranes for pallor or cyanosis
4. Assess for restlessness and changes in LOC
5. Use pulse oximetry to monitor O2 saturation, assess ABG's
1. An increase in RR and depth may be a compensatory response for airway obstruction. The breathing pattern may alter to include use of accessory muscles to increase chest excursion to facilitate effective breathing.
2. Pts may have ineffective cough because of fatigue. A sign of infection is discolored sputum and odor may be present.
3. Airway clearance is impaired with inadequate hydration and thickening of secretions. Thick, tenacious secretions increase hypoxemia.
4. Bronchial lung sounds are commonly heard over areas of lung density or consolidation. Crackles are heard when fluid is present.
5. Secretions from pneumonia are often foul tasting and smelling. Providing oral care may decrease nausea and vomiting associated with the taste of secretions.
1. Assess respirations, noting rate, rhythm, depth and use of accessory muscles
2. Assess cough for effectiveness and productivity. Observe characteristics of sputum: color, amount and odor and report significant changes.
3. Assess hydration status.
4. Auscultate lungs, noting areas of decreased ventilation and presence of adventitious sounds.
5. Provide oral care.
1. Fluid promotes urine production and flushes bacteria from the urinary tract
2. A regular pattern of urination enhances bacterial clearance, reduces urine stasis and prevents reinfecton.
3. Drugs may be used in combination to reduce development of bacterial resistance. Long-term antibiotic therapy may be prescribed from pts with chronic UTI's.
4. Catheters increase the risk for infection. Only use as necessary.
5. The inflammatory response associated with infection leads to WBC and WBC in the urine and identification of the causative organism is necessary for selecting the most effective antibiotic.
6.Accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system
1. Give fluids to keep pt. hydrated
2. Empty drainage bag often and as needed
3. Administer prescribed antibiotic
4. Only use indwelling bladder catheter as needed
5. Assess laboratory data including, urinalysis and WBC
6.Observations of changes in mental status:, behavior or level of consciousness
1. COPD pts have increased nutritional needs because of the work of breathing.
2. Pts need to learn self-management skills to reduce dyspnea from fatigue.
3. Respiratory infections can increase the work of breathing and precipitate respiratory failure.
4. Breathing exercises strengthen the muscles of respiration and developes slow, controlled breathing.
5. Objective data guide ongoing management.
1. Discuss appropriate nutritional habits, including supplements as appropriate.
2. Discuss the concept of energy conservation. Encourage resting as needed during activites.
3. Discuss signs and symptoms of infection and when to contact the health care provider.
4. Discuss the importance of specific therapeutic measures such as breathing exercises
5. Discuss the need for periodic reevaluation to determine oxygen needs.

Discharge Planning
Cameo Johnson and Yadira Garcia NUR222 Concept Map 1 02/01/2015
Impaired gas exchange
Ineffective Airway Clearance
Impaired Urinary Elimination
Deficient Knowledge of COPD
Community Services

Pt will be discharged to Sierra Blanca and will utilize the services offered at that location.
Anticipated teaching:

Recognition of the s/s of pulmonary infection and of urinary tract infection

Teach management of COPD including breathing techniques, relaxation techniques and activity only as tolerated.

Teach importance of handwashing and avoiding crowds or individuals with known infection.

Follow up: with PCP for repeat labs including CBC, CMP, urinalysis, consider chest x-ray within 9 weeks of discharge.

Color: yellow
Clarity: clear
Specific Gravity: 1.010 Normal
Urine pH: 5.5
Urine Leuk Esterase: 3+
Urine Nitrite: Neg
Urine Glucose: Neg
Urine Protein: 1+
Urine Ketones: Neg
Urine Bilirubin: Neg
Urine Blood: 3+
Urine WBC: <50
Urine RBC: 50-100
Urine Culture Setup

pH: 7.375 Normal
PCO2: 42.8 Normal
PO2: 70
EST SO2: 98.4
HCO3: 24.5 Normal
FIO2: 40
PO2/FIO2: 3.15
Allens Test: Positive
Ventilator Mode: BIPAP
Set rate: 16
Pressure Support: 8
Desired Outcome:

Patient experiences improvement by relaxed facial expression and body movements
stable vital signs by discharge.

Evaluation ongoing. Patient was admitted to ICU from ER continue to monitor and support.
Expected Outcome:
Patient maintains optimal gas exchange as evidenced by ABG's within the patient's usual range, "O2 sat of 90% or greater, alert response mentation and no further reduction in LOC by discharge.
Ongoing. Patient was transferred to ICU from ER.
Expected Outcome:
Pt will maintain clear, open airways as evidenced by eupnea and normal breath sounds and normal rate and depth of respirations by discharge.
Ongoing. Patient was transfered to ICU from ER for ongoing evaluation of airway clearance.
Expected Outcome:
Pt is free of UTI as evidenced by clear, non-foul smelling urine, pain-free urination, normal WBC count and absence of fever, chills, flank pain, urgency and frequency by discharge.
Ongoing: Patient was transferred to ICU from ER where evaluation of UTI is ongoing.
Desired Outcome:
Pt verbalizes understanding of disease process and treatment by discharge.
Ongoing. Pt was transferred to ICU from ER and is unable to verbalize at this time due to decreased mentation. Evaluation of pt teaching and understanding of disease process of COPD is ongoing.
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