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Med Surg 3 Concept Map

Toni Dunn

Patient Snapshot

T.T.

72 yr old. Male.

Full Code

Allergies: Aspirin, Fentanyl, Elipta, Victoza

Height: unknown

Weight: 143 lb

Dx: aspiration pneumonia

Chief Complaint

Dyspnea on Exertion

Chest Discomfort

Shortness of Breath

Chief Complaint

Other Orders

Diet: NPO-ice chips

Oxygen via Nasal Canula 2L

Respiratory Treatments PRN

HOB >30

Strict I/O

Vital Signs Q4

Fall Precautions

Q2 Turn

Other Orders

Patient Demo

Patient is an older male who lives at home independently. He recently developed aspiration pneumonia and is having a difficult time recovering.

Since the infection, he has difficulties with everyday activities, and decreased ability to care for himself.

Health Hx:

COPD, Hx of carcinoma of larynx, acute on chronic respiratory failure, lung cancer, Hx. of pulmonary embolism.

Pathophysiology

Aspiration Pneumonia is when normal body defense mechanisms fail and there is entry of fluid into the bronchi and alveolar space

S/S: chest pain, coughing up sputum or phelgm, fatigue, shortness of breath, fever, problems swallowing, and wheezing

Assessment Findings

Respiratory: Regular, unlabored, chest expansion symmetrical, fine crackles throughout lungs lower bases are diminished to ausculatation. Productive cough. Nasal Canula 2L.

Cardiac: NSR, no abnormal sounds. Telemonitor present.

Peripheral Vascular: +2 bilateral radial pulses, +2 bilateral pedal pulses. Cap refill <3 seconds. No edema noted.

GI/GU: Bowel sounds present in all 4 quadrants; active. Last BM 11/15/2022. PEG tube, dressing changed 11/16/2022-clean dry and intact.

Musculoskeletal: Full ROM in upper and lower extremities. Generalized weakness bilaterally in legs.

Neurological: A/Ox4, Clear Speech, follows commands.

Integumentary: Color appropriate, warm/dry. Normal skin tugor.

HEENT: All intact. No drainage from nose. Mucous membranes pink, moist and intact.

Vital Signs

0715: 37.6C oral, P 83, R 18, O2 93% RA, 104/58 BP. Pain 0 out 10

1505: 37.4C oral, P 77, R 18, O2 95% RA, 121/67 BP. Pain 2 out 10

Vital Signs

Labs

Na: 136

K: 4.4

C: 94

CO2: 36

WBC: 10.6

HGB: 13.6

HCT: 38.9

PLT: 368

Glucose: 193

BUN: 10

Creatinine: 0.6

eGFR: >90

Medications

Pantoprazole (protonix) - 40 mg - IVP - daily

Classification: proton pump inhibitor

Side Effects: heachache, dizziness, stomach pain, nausea/vomiting, fever, rash

Nursing Considerations: advise not to drink alcohol, avoid gi irritation, monitor for signs of gerd

Potassium Phosphate - 500mg - PO-PEG tube - 3x daily.

Classification: minerals/electrolytes

Side Effects: confusion, weakness, nausea, lightheadedness, decrease HR, weakness in legs.

Nursing Considerations: monitor K+ levels, monitor heart rate and rhythm, crush/dissolve well for tube administration.

Sodium Chloride 0.9% (NS) - 3-10 mL - IV - Q12hrs and PRN.

Classification: Electrolyte. Line care.

Side Effects: nausea, vomiting, edema.

Nursing Considerations: monitor IV site, electrolytes and fluid overload.

Diltiazem (cardizem) - 90mg - PO-PEG tube - every 6 hours

Classification: calcium channel blocker

Side Effects: decrease HR, fluttering chest, shortness of breath, nausea, skin reaction, swelling, headache

Nursing Considerations: monitor BP/ Pulse, mix/crush with hot water for tube administration.

Medications

insulin lispro - sliding scale - subcutaneous - with meals

Classification: insulin

Side Effects: hypoglycemia, swelling, weight gain, itching

Nursing Considerations: monitor blood glucose, use as prescribed, check sugar before eating meal, rotate injection sites

senna leaf extract - 17.2mg - PO-PEG tube - daily

Classification: herb/laxative

Side Effects: dehydration, diarrhea, loose stool, electrolyte imbalance

Nursing Considerations: avoid dependence, monitor for obstruction-do not give if suspected

Levothyroxine (synthroid) - 25mcg - PO -PEG tube - daily

Classification: thyroid drugs

Side Effects: shortness of breath, tremors, headache, leg cramps, weight loss, rash, diarrhea

Nursing Considerations: do not give with food, monitor heart.

Levaquin (levofloxacin) - 750mg - liquid - PEG tube

Classification: quinolones

Side Effects: nausea, vomiting, constipation, diarrhea, headache, dizziness, trouble sleeping

Nursing Considerations: increase fluids, monitor for side effects

Nursing Diagnosis

Activity Intolerance r/t decreased O2 stats AEB O2 % in the 70s when ambulating, and overall SOB

Imparied Gas Exchange r/t COPD/inflammation AEB dyspnea, restlessness, and lethargy

Ineffective airway clearance r/t secretions in the bronchi and alveoli AEB shortness of breath, diminished lung sounds, restlessness

Nursing Diagnosis

Risk For Falls r/t generalized weakness and lack of physical therapy

Risk for infection r/t worsening in condition leading to immobility, immunosuppression, and malnutrition

Activity Intolerance

Activity Intolerance

Goal: Patient will be able to independently perform ADLs before discharging home.

Assess patients current level of activity and tolerance to activity.

-Allows nurse to evaluate where pt is beginning to help develop plan to improve pts activity.

Assess pts vital signs.

-Gives nurse and staff baseline and way to gauge potential changes and fluctuations in vital signs when active.

Assess underlying cause of activity intolerance.

-Allows for appropriate treatment for any underlying causes.

Assess nutritional status.

-Patients body requires certain nutritional needs in order to be active. High importance to ensure nutrtional needs are being met.

*Patient was able to express needs for further physical therapy and help before being able to return home, care management contacted to potentially transfer patient to short term nursing skilled facility.

Impaired Gas Exchange

Goal: The patient will participate in procedures to optimize oxygenation and in management regimen within level of capability/condition.

Assess respiratory rate, depth, and effort while resting and ambulating.

-rapid shallow breaths effect gas exchange, signs of distress can be seen with hypoxia.

Assess lungs for areas of decreased ventilation and auscultate presence of adventitious sounds.

-any irregularity of breath sounds may disclose the cause of impaired gas exchange. The presence of crackles and wheezes may lead to exacerbating exisiting hypoxia.

Monitor patients behavior and mental status for the onset of restlessness, agitation, confusion, and extreme lethargy.

-changes in behavior and mental status can be early signs of impair gas exchange.

Monitor for signs of hypercapnia.

-buildup of carbon dioxide in the bloodstream. S/S include headache, dizziness, lethargy, disorientation, and reduced ability to follow instructions.

Goal partially met AEB pt started to realize he needed additional assistance to improve condition before being able to go home independently.

Ineffective Airway Clearance

Ineffective Airway Clearance

Goal: Patient will demonstrate appropriate airway clearance techniques.

Assess the ability and effectiveness of cough.

-pneumonia infection causes inflammation and increased sputum production. Secretions need to be able to be removed to maintain patent airway.

Administer nebulizer treatments and other medications.

- help loosen secretions in the lungs, thin mucus, making it easier to cough up.

Encourage movement and positioning.

-helps promote lung expansion.

Suction as needed.

-ineffective cough patients may need suction to get secretions out.

Goal met AEB patient showing effective ways to help clear airway, and get rid of secretions.

Risk for Falls

Risk for Falls

Goal: Patient will remain free from falls during this admission.

Assess history of falls.

- Individuals are more likely to fall again if they have had one or more falls within the last 6 months.

Assess patient for sensory deficits.

- Sensory perception of environmental stimuli is huge for safety.

Assess the use of mobility assistive devices.

- Inappropriate use increases energy usage, unsteady gait, increasing risk for injury/falls.

Assess for disease-related symptoms.

-falls are more likely to happen when patient experiences symptoms to increase them; ie. hypotension, edema, dizziness, and weakness

*Patient remained free of falls during admission thus far, goal was partially met.

Risk for Infection

Goal: Patient will remain free from further infection during this admission.

Monitor for worsening signs of infection or sepsis.

-dropping blood pressure, hypothermia hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attnetion.

Assess lab values.

-elevated WBC is indicative for infection. This is expected with pneumonia, but shoul dnot continue to rise with treatment. If sepsis is suspected, draw blood cultures.

Administer antibiotics.

-pneumonia warrants antibiotic treatment. If condition worsens, or labs do not improve, patient may not be receiving correct antiobiotics.

Encourage fluid intake and nutrition.

-hydration is vital to prevent dehydrationand supports homeostasis. Fluids help kidneys filter and flush waste products preventing renal and urinary infections. Proper nutrition promotes energy and supports the immune system.

Goal partially met, patient did not have any worsening infection symptoms this far in admission. Goal will be met if patient does not show signs of worsening infection thru discharge.

Discharge Planning

Patient will continue to see OT and PT while admitted to help build strength.

Patient will discharge to skilled nursing facility to help increase strength and abilities to live independently, once successful patient will go home.

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