Fortis College
Nursing Care Plan
Patient Demographics
Student: _Brenda Davis_____ Clinical Site: __JVH_______ Date: ___08/06/2014_______________
Client Initials: __E.D.__ Age: __65_______ Weight: _75.7 kg Height: ___69________in.
Primary Language:_English____ Religion: _LDS, active in church__ Culture: __Retired lives with daughter and son-on law, they are at the bedside off and on throughout the day____________________
Admitting Diagnosis: ___Pneumoia_________________________________________________________
Secondary Diagnosis: __Hypoxia___________________________________________________________
Allergies & Reactions: __No Allergies_______ Code Status: DNR_____ Physician:__Chandler________
History of Present Illness (Please include a detailed description of the present illness including past medical and surgical history-paint a picture) What brought your client to this facility?
Mrs. D is 65 year old Caucasian female presents in the ED for shortness of breath and difficulty taking deep breaths. Past medical hx includes depression, anxiety and MS. Past surgical history includes hernia repair. Patient reports she has 4 children and 3 of them live in other states. Her daughter that lives locally is her primary caregiver. Patient does not smoke “quit 20 years ago and smoked 1 pack a day for 15 years” and she does not drink. She was admitted to the facility 8/4/14 for pneumonia and hypoxia. Patient is unable to take care for self she requires assistance with ADL’s. Patient reports that when she takes a deep breath in, has pain on the right side. Has unproductive cough, decreased lung sounds in all lung fields. Unable to get adequate sleep because of Shortness of breath. Ego integrity vs despair stage of development. Alert and oriented x’s 3. Patient is forgetful when family is in the room. Mood appropriate.
Orders/Treatments (include cares/procedures ordered for the patient except for med and labs)
Monitor Vital signs every 4 hours, O2 @ 6 lpm NC to keep O2 above 90%. Can switch to re-breather mask if oxygen saturation requirement is not met. Antibiotics. Telemetry.
Pathophysiology (Include Pathophysiology of the presenting diagnosis at the cellular level – not procedure or surgery –Include treatments as well as relating your “text book” picture to your patient).
Pneumonia- Microorganisms enter the alveolar spaces by droplet inhalation, inflammation occurs, and alveolar fluid increases. As a result, gas exchange is impaired and ventilation decreases as secretions thicke Pneumonia has caused an infection of the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, causing fluid into the alveoli causing disruption in gas exchange, which makes breathing painful and limits oxygen intake (Lewis, 2011).
Hypoxia reduction in PO2 below the normal range, regardless of whether gas exchange is impaired in the lung, it is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. When an individual has pneumonia the patient has limited gas exchange which results in hypoxia (Lewis, 2011).
Physical Assessment
Body Systems
Actual or Potential Nursing Diagnosis
General Appearance: 65 year old woman, appears older than stated age
Vital Signs:
B/P 128/78 L arm sitting
Temp: 99.5 F Tympanic Pulse: 72 bpm Respiration: 18 bpm
Oximetry: 94 % on 6 lpm n/c
Pain Assessment: reports no pain currently. Often has pain 4/10 when coughing. Dull pain that is relieved by sitting up in bed.
Ineffective breathing pattern r/t pneumonia
Activity intolerance r/t imbalance between oxygen supply and demand.
HEENT:
Inspect Head: No Lesions present
Visual Acuity Wears corrective lenses
Hearing acuity: No evidence of hearing aids, patient responds to whisper test.
Nose: Mucosa is pink and moist. Septum is midline. Nares are patent with no drainage
Mouth/Throat: Trachea is midline. Patient wears dentures upper and lower. Oral mucosa is pink, moist with no lesions.Lymph nodes non palpable.
Neurological:
Orientation: Alert and oriented X’s 3 when in the room alone. When family is in the room the patient is forgetful and often oriented only to self. No acute signs of distress, patient canfollow verbal commands
PERRLA
Gross Motor sensation is present in all extremities
Swallow: Gag reflex not assessed, but patient swallows without difficulty
Cranial Nerves: See previous body systems
Respiratory:
Breathing inspection:Respirations 18/min, shallow and even
Breath Sounds:Decreased coarse breath sounds auscultated over all lobes
Chest expansion symmetric, mildrefractions. No pain or tenderness on palpation. Pain on inspiration
Cough:non-productive cough present
Oxygen therapy:94% on 6L/min
Skin Color:pink, intact, no edema
Impaired gas exchange
Cardiovascular:
Edema: No edema present
Pulses- Apical 72 bpm regular rhythm, all other pulses 2+ strong bilateral
Auscultation: S1 and S2 auscultated. Carotid pulse equal bilateral, no bruits auscultated. Regular rate and rhythm without murmurs.
Capillary Refill:
Gastrointestinal:
Inspect abdomen: Soft, non-tender, non-distended upon palpitation. Skin of abdomen free of lesions and rashes.
Bowel sounds x4: Active Bowel sounds in all 4 quadrants.
Last BM: Last BM was today, normal consistency, patient is in a brief but will ask to go to the bathroom.
Diet/Appetite : Mechanical soft diet, needs assistance to eat. Ate 50% of meals today.
Imbalanced nutrition: Less than body requirements related to inability to eat on own
Genitourinary:
Catheters: 18 French catheter
Quality of Urine: Dark amber urine
Continence: incontinent.
Voiding Frequency Urgency: without urgency
Painful: denies painful urination
Musculoskeletal:
ROM, strength upper & lower extremities: Limited ROM in lower extremities. Full ROM in upper extremities. Wheelchair bound
Activity Level: Up to chair with assistance.
Gait: uneven gait. Will stand and shuffles to try walk.
Integumentary:
Skin: pink, warm to touch, turgor rapid recoil,no edema, cyanosis, or clubbing
Drains, drainage, dressing: 18 g LEJ ½ NS @ 50cc. Dressing clean, dry intact without redness or swelling. No other dressings or drains noted
Pressure Points: Braden scale 14 high risks. Morse fall scale 28 high risk
Emotional/Psychological: Anxious, angry etc: Patient is very pleasant when she is alone. Appears anxious when family is in the room with her.
Appropriate: Appropriate to situation
Sleep Patterns: Altered sleep patterns, patient is restless. Nurse reports patient only slept 3 hours last night. Patient states “I am very tired.”
Erickson’s developmental stage: Ego vs. Despair
Impaired comfort r/t hospitalization
Anxiety related to change in health status
LABS
Lab Test
Patient Value
Admit Current
Normal Range
Rationale for Abnormal (apply this to YOUR patient)
CBC
RBC
4.1-6.0
Hgb
11.0 (l)
12-18g/dL
Low related to pneumonia and decreased oxygenation (Pagana, 2010)
Hct
33.0 (l)
38-48%
Low related to pneumonia and decreased oxygenation (Pagana, 2010)
WBC
8.0
5.0-10.0
Neutrophils
56.4
55-70%
Lymphocytes
28.0
20-35%
Monocytes
4.2
3-8%
Eosinophils
1.5
1-3%
Basophils
0.7
0.5-1%
Bands
0-11%
Platelets
210
150-400
CMP
Na+
143
135-146mEq/L
K+
2.6 (l)
3.5-5.1mEq/L
Low due to dehydration or other electrolyte imbalance (Pagana, 2010)
Cl-
108
95-105mEq/L
CO2
30
24-32mEq/L
Glucose
103
60-110mg/dL
BUN
13
6-20mg/dL
Creatinine
.7
0.6-1.4mg/dL
Calcium
9.2
8.5-10.5mg/dL
Total Protein
6.1
6.0-8.0g/dL
Albumin
3.9
3.5-5.0g/dL
Alk Phos
90
38-126 U/L
ALT
11
10-35 U/L
AST
15
8-38 U/L
GGT
4-23 U/L
Phosphorus
3.0-4.5 mg/dL
Magnesium
1.3-2.5mEq/L
CRP
ESR
0-20mm/hour
PT
INR
9.5-12 sec
1.0 (normal)
2.0-3.0 (therapeutic)
PTT
20-45 sec
LIVER
Total Bilirubin
0.1-1.0 mg/dL
Direct Bilirubin
0.0-0.4 mg/dL
Indirect Bilirubin
0.4-1.0 bg/dL
Ammonia
15-45mcg/dL
CARDIAC
Total Cholesterol
140-200 mg/dL
LDL
60-160 mg/dL
HDL
29-77 mg/dL
Triglycerides
40-190 mg/dL
CK
25-200 U/L
CK-MB
0-7 U/L
Troponin
BNP
GASTROINTESTINAL
Amylase
56-190 U/L
Lipase
0-110 U/L
H. pylori
Negative
Stool Occult Blood
Negative
ENDOCRINE
TSH
0.5-5.5uU/mL
T3
800-200ng/dL
T4
4-12ng/dL
Hgb A1c
4-7%
RESPIRATORY
ABG
pH
7.35-7.45
pO2
80-100mmHg
pCO2
35-45mmHg
HCO3
22-26mEq/L
URINALYSIS
pH
4.6-8.0
Specific Gravity
1.01-1.025
Protein
Negative
Glucose
Negative
Ketones
Negative
Bilirubin
Negative
Nitrites
Negative
Leukocyte esterase
Negative
WBC
0-5/hpf
RBC
0.4/hpf
Casts
None to occasional
CULTURES
Urine
No Growth
Stool
No Growth
Wound
No Growth
Blood
No Growth
Sputum
No Growth
DIAGNOSTIC TESTS
DIAGNOSTIC TEST
DATE
PATIENT’S TEST RESULTS AND RATIONALE
EKG
X-RAY
8/4/14
CXR single view. Low lung volumes are present. No pneumothorax. Bilateral lower lobe pneumonia
ULTRASOUND
CAT SCAN MI
ULTRASOUND
CARDIAC CATHETERIZATION
ECHO
VENOUS DOPPLER
BRONCHOSCOPY
BIOPSIES
SCOPES (EX. Colonoscopy)
LUMBAR PUNCTURE
EEG
Other:
MEDICATIONS
Drug /Trade & generic /Class
Dosage/route/schedule
Reason for Use
Nursing Consideration
Levaquin/Levofloxacin
Anti-infective broad spectrum antibiotic that inhibits DNA into bacteria
750 mg PO daily
Treatment of pneumonia
Obtain C & S prior to therapy, Assess for previous allergic reaction, monitor I & O, assess for diarrhea (Skidmore-Roth, 2013).
Enoxaprin/Lovenox
Low molecular heparin with antithrombotic properties
40 mg SC daily
Prevention of clots
Assess coagulation studies, monitor bleeding (Skidmore Roth, 2013).
Tylenol
625 mg Q4hrs prn
Pain or fever
Monitor for S&S of: hepatotoxicity , Do not take other medications containing acetaminophen without medical advice (Skidmore Roth, 2013)
Prozac/fluoxetine hydrochloride
elective serotonin reuptake inhibitor
40 mg PO daily
Depression
Use with caution in the older adult patient, lab tests: periodic serum electrolytes; monitor closely plasma glucose in diabetes, serum sodium level, weigh weekly to monitor weight loss (Skidmore Roth, 2013).
Xanax/alprazolam benzodiazepine
1 mg PO prn
anxiety
Assess anxiety, Monitor BP, Monitor hepatic function and CBC with long time use. Assess mental status (Skidmore Roth, 2013).
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)
Rationale
Give one reason for each nursing intervention that is performed.
Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
# 1.
Impaired gas exchange r/t inadequate airway and alveolar clearance secondary to pneumonia, aeb decreased coarse breath sounds and shortness of breath (Ackley, 2012).
Patient will demonstrate the use of incentive spirometer 10 times every hour by 1 pm.
Patient will remain free of respiratory distress and maintain clear lung fields throughout the shift.
Assess LOC and distress.
Monitor respiratory rate and depth and ease of breathing. Watch for use of accessory muscles and nasal flaring.
Teach how to use incentive spriometer and deep breathing exercises.
May indicate worsening hypoxia.
Indicates if there is a change in respiratory status.
Helps open up the airway for ventilation and keeps alveoli open.
Patient is using incentive spirometer, patient is partially meeting goals.
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)
Rationale
Give one reason for each nursing intervention that is performed.
Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
# 2.
Ineffective breathing pattern r/t pneumonia aeb SOB, shallow breathing, and decreased oxygen saturation levels (Ackley, 2012).
Patient will be able to verbalize understanding of proper deep breathing techniques by 1 pm.
Patient will establish normal breathing patterns by discharge.
Assess respiration rate, rhythm, and depth.
Monitor deep inspirations to increase oxygenation.
Teach appropriate deep breathing, and coughing techniques.
Early signs of respirator difficulties.
Increase oxygenation.
Clears secretions.
Patient is working on deep breathing. Patient demonstrates understanding of deep breathing and coughing to clear lungs. Goals are partially being met at this time.
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)
Rationale
Give one reason for each nursing intervention that is performed.
Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
# 3.
Impaired comfort r/t hospitalization aeb restlessness, disturbed sleeping patterns, and confusion (Ackley, 2012).
Identify strategies to improve or maintain comfort by 10 am.
Maintain an acceptable level of comfort throughout shift.
Assess patients current level of comfort.
Enhance feelings between the patient and those providing care.
Offer suggestions for improving comfort by breathing to relax and utilize empathy in response to patient’s negative emotions.
Identifies baseline for patient.
To attain the highest comfort, patient must trust those providing care.
Helps patient to identify strategies that work for her. Empathy also promotes trust.
Patient is developing trust with the hospital staff. However, when family is present patient does not speak up. Goals are not being met currently.
References
Ackley, B. J. &Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. (10th ed.). St. Louis, MO: Mosby Elsevier.
Jordan Valley Hospital, Electronic medical records, West Jordan UT.
Lewis, S.,Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby-Elsevier.
Pagana, KathleenDeska,Pagana, Timothy J. (2010). Mosby’s Manual of Diagnostic and Laboratory Tests (4thed). St. Louis, MO: Mosby Elsevier.
Skidmore-Roth, Linda, (2012) Mosby’s Drug Guide for Nurses, with 2012 Update: 9th Edition
Essay Writing Service Features
Our Experience
No matter how complex your assignment is, we can find the right professional for your specific task. Contact Essay is an essay writing company that hires only the smartest minds to help you with your projects. Our expertise allows us to provide students with high-quality academic writing, editing & proofreading services.
Free Features
Free revision policy
$10Free bibliography & reference
$8Free title page
$8Free formatting
$8How Our Essay Writing Service Works
First, you will need to complete an order form. It's not difficult but, in case there is anything you find not to be clear, you may always call us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download