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Nursing 3360 Caremap
Transcript of Nursing 3360 Caremap
Height: 5ft. 3 in.
Weight: 68.6 kg
Father: CAD; Diabetes
Social and Personal Hx:
primary language: English
Home Situation: Resident at Kidred Greenfield
Martial Status: married
Financial Situation: retired living off social security has medicare
Allergies: No known allergies.
Past Medical Hx:
Hypokalemia,DM, confusion, SOB
SOB, Chest pain
Name Dose Frequency Reason for taking Side Effects Pharm Class
improve urine output
decrease mucus thickness
decrease mucus thickness
increase normal flora
dizziness, orthostatic hypotension, weakness
Flu Shot -2013
RBC--- 3.38 low: watch for anemia, dehydration
MCHC PLT--- 28.4
Na--- 137 low: headache, nausea,muscle crapms, respiratory arrest
Glucose--- 64 low: confusion,
BUN--- 55 high: Kidney function, bleeding dehydration
Cr--- 1.42 high: kidney function. dehyrdation
pH--- 7.26 low monitor for acidosis
PCO2--- 56 high ,respiratory acidosis
constipation, loss of appetite, cough
nausea, tinnitus, drowsiness
diarrhea, tinnitus, stomach pain
dizziness, changes in vision, incraesed salivia
swelling, nausea, mild pain
weight loss, vomiting, tiredness
weakness, bradycardia, dizziness
stuffy nose, sweaty, diarrhea
bleeding, bruising, terry stools
constipation, headache, dizziness
delirium, sedation, dizziness
dehydration, dizziness, hypokalemia
dizziness, rash, trouble breathing
dizziness, rash, trouble breathing
anxiety, tachycardia, dysrythmias
hypotension, tinnitis, insomnia
headache, abdominal pain, urinary retention
diahrrea, hyperglycemia, headache
cough, ALS, muscle cramps
dark urine, fatigue, icterus
Chief Complaint: CHF;SOB
Nursing dx 2: Risk for impaired skin integrity r/t immobilization aeb reddened skin on buttocks.
Long Term: Pt will verbalize a personal plan for preventing impaired skin integrity by discharge.
Short term: Pt will regain skin integrity on surface and skin will remain intact by the end of clinical shift.
Assess learning style by asking pt. and pt.'s family.
(Knowing the patients learning style can alter how you teach the patient .)
Use the Braden scale to assess risk factor due to immobility.
Arrange time in schedule to meet with patient for ten minutes a shift to discuss risk factors for skin breakdown.
(Making time in your schedule everday will help reiterate )
Implement a written prevention plan the patient can use at home.
(Implementing a prevention protocol ccan significantly reduce costs and incidence of skin breakdown nanada, 2011)
Turn pt. every two hours.
( Reduces risk of skin breakdown by decreasing constant pressure on the same area of skin.)
Apply skin barrier
cream. To reddened area.
(Skin barrier cream can help protect against friction and shear which both contribute to skin breakdown)
(Massaging over bony prominences can lead to deep tissue trauma Nanda, 2011)
Monitor skin condition every four hours. Note any redness, moisture or pressure spots.
(Systematic inspection can identify impending problems early. Nanda, 2011)
58 year old female was brought into the emergency room with altered mental status, difficulty breathing, and diarrhea. Pt. was brought up to ICU and intubated on 2/23. Pt. stool tested positive for lactoferrin.
Skin: Pt. has red area approx 2 by 4 in on right buttocks.Pt. is warm, no cyanosis, skin turgor is good.
HEENT: Pt. has good hearing and due to intubation problems chewing, swallowing and talking.
Cardiovascular: Pt. has hx of hypertension, SOB, Chest Pain and a pedal pulse of 2 plus bilateral. Capillary refill is 3 seconds on RUE. S1&S2 regular, sinus rythm HR rate 69 no mumurs
Respiratory: Pt has hx of COPD and pneumonia. Pt. has an A:P ratio of 1:2. Pt. has 7.5 ET tube, lip line at 23. Lung sounds diminished at bases and is on a vent on F102 setting.
GI: Pt has hx of GERD. Hypoactive bowel soundsleft lower quadrant. Abdomen has no signs of masses, hernies, slighyty distended and is soft and round. last BM 2/24 stool tested positive for lactoferrin
Musculoskeletal: Pt. has weakness in right and left upper extremity. Required maximal assistance with all ADL's. wiggle feet upon command.
Safety: Pt is not at fall risk uses a wheelchair and has bed alarm on and side rails up as indicated with call light within reach.
Psychiatric: Pt. has hx of depression and anxiety.
Endocrine: Pt has hx of thyroid disease and is a type two diabetic.
Neuro: Pt. has hx of memory impairment, CVA and confusion. Pt, sedated, eyes openingto voice, withdrawls from pain. Pupils size 2 to 1, sluggish.
Hematology: Pt. has some bruising on both arms and Celiac disease, anemia, an dclotting problems.
Vital Signs: BP- , HR 69, R 12, O2-95 on vent, Temp- 97.2 F axillary, Pulse-71 Intake- 250ml Output- 1000ml
Nursing dx 1:Impaired gas exchange r/t ventilatior-perfusion imbalance aeb O2 saturation of less than 90 %.
Short term goal: Pt. will increase perfusion balance aeb an O2 saturation above 90% before the end of clinical shift.
Monitor oxygen saturation continuously using pulse oximetry.
Suction pt. and provide vent care every two hours and as needed.
Auscultate breath sounds listen for diminshed or absent lung sounds every 2-4 hours.
Have pt. sit upright at 30 degrees or stand at least two times a day to avoid lying down for prolonged periods.
Long term goal: Pt. will demonstrate improved ventilation and oxygenation of tissues aeb ABG values within normal limits by discharge.
Increase pt.s' activity to walking three times per day down the length of the hallway as tolerated.
(Supervised exercise has been shown to decrease SOB and increase tolerance to activity Nanda, 2011)
Schedule rest periods of at least fifteen minutes before and after activities such as bathing, dressing or ambulating.
(Pt. needs to rest before and after activities to help reduce shortness of breath allowing more oxygenation and ventilation.)
(An erect posture fosters maximal lung expansion Nanda, 2011)
Lab values out of normal range
Nursing dx and long-term short-term goals
(pulmonary rehabilitation has been shown to help relieve dyspnea and increase ventilation. )
(abnormal lung sounds can indicate a respiratory pathology associated with an altered breathing pattern Nanda, 2011)
(O2 saturation of less than 80% indicates significant oxygenation problems Nanda, 2011)
( A validated scale can help identify how at risk the patient is Nanda, 2011)
(If the patient is able to verbalize plan to reduce skin breakdown that is a good indicator that they understand the risk factors and will implement plan at home.)
(The pt. is immoblized which puts her at high risk for skin breakdown and already has early signs so prevention of further breackdown is important.)
(patient is at risk due to immobility and has some reddened area so implementing a plan to prevent skin breakdown is important.)
( Airway is the highest proiority Pt. has COPD is on a vent and needs to start working towards the goal of getting off the vent)
( Getting the patient to increase perfusion is the short term goal. The pt. can demonstrate this by having an 02 saturation of above 90%.)
( Having normal ABG values is a good indicator of having good ventilation and oxygenation of the tissues which is extremely important.)
(Providing suctioning can help keep airway and lungs clear allowing the pt. to breathe easier. Providing mouth care can help pt. comfort.)
Discharge date is yet to be determined, therefore unable to evaluate and determine goal. Prior to discharge I will continue interventions to help patient inrcease ventilation and oxgenation and to help ABG's return to normal
Keeping same goal: Pt. will demonstrate improved ventilation and oxygenation of tissues aeb AGB values within normal limits by discharge.
Pt. was able to maintain an O2 saturation above 90% by the end of the clinical shift. O2 saturation was measured at 93%.
Keeping the same goal: Pt. will increase perfusion balance aeb an O2 saturation above 90% before the end of clinical shift.
Pt. had no increase in reddened area and skin remained intact. Goal of regaining skin integrity on surfec and skin remaining intact was met.
Keeping same goal: Pt will regain skin integrity on surface and skin will remain intact by the end of clinical shift.
Discharge date is yet to be determined, therefore unable to evaluate and determine goal. Will continue interventions every clinical shift to help reach goal before discharge.
Keeping same goal: Pt will verbalize a personal plan for preventing impaired skin integrity by discharge.
Summary: Interventions seem to be effective. Pt. has a better oxygen saturation(above 90%) and all precautions to prevent futher skin breakdown are being implemented. However the pt. will need to continue to be on a ventilator until ventilation improves and ABG's return to normal. I could have focused more on how the patient's CHF was affecting breathing. I could have done a dx r/t CHF.
Other possible dx:
Impaired activity tolerance related to SOB.
Code Status: Full Code
beta 2 adrenergic receptor agonist
proton pump inhibitor
Ackley, B. and Ladwig, G.(2011). Nursing Diagnosis Handbook.St louis MI: Mosby Elsevier.
Avoid massaging over bony prominences.
(pH 7.35-7.45,HCO3 22-26,PaCO2 35-45)
Refer pt. to Pulmonary rehabilitation program.
Help the client deep breathe and perform controlled coughing.(inhale deeply hold a few seconds and cough while tightening abdominal muscles)
(Controlled coughing helps uses diaghragmatic muscles which makes the cough more forceful clearing airways)
Creatine and BUN signs of kidney failure. Doctors discussed chances of needing to start dialysis.
ABG's show respiratory acidosis which could mean poor oxygenation and ventilation.
Developmental stage: Generativity vrs. stagnation
( risk factors assessed include nutrition, immobility, moisture, sensory perception actvity, and friction and sheer)
( risk factors include nutrition, immobility, moisture, sensory perception actvity, and friction and sheer)