Roosevelt
Care Plan
Student Name: Scott Poppen
Pt.’s Age/Gender:
65
female
Admission
Date:
03/28/2022
Allergies: None
Instructor: Cora Palmer
Admitting diagnosis:
Pneumothorax
Date of care: 04/07/2022
Code status: none
Advance directives: none
BMI: Weight (lbs)
Primary (highest priority) Nursing Diagnosis/Problem:
Impaired gas exchange related to decreased functional lung tissue
caused by pneumothorax as evidenced by abnormal dyspnea and ABGs
IV fluids: 0.9% Saline
IV rate: 50/hr
Significant Secondary Nursing Diagnosis/Problem:
Risk for acute pain related to positive pressure in the pleural space
Level of function prior to admission:
not independent needed assistance
with ADL dependent on others.
Assistive devices used/prosthetic limb(s): Rolling walker
Past surgical history:
Past medical history: HTN, edema, type II diabetes, COPD
NURSING ASSESSMENT FINDINGS
Initial (morning) vital signs:
Repeat: (if relevant)
HR-80/min
BP-150/80
SpO2- 89%
Temp- 98
Respiration - 18/min
MPAP- 31
Neurological
responsiveness/orientation/
LOC motor/sensory
speech/attentiveness/mem
ory cranial nerves (if
relevant)
RLE, LLE, RUE. LUE all have increased weakness and decreased sensation
related to edema and Diabetic neuropathy.
EENT (eyes, ears, nose,
throat) redness, jaundice,
discharge, bleeding,
burning, or pain
Hard of hearing L & R. Patient has lenses in both R & L eyes.. Missing teeth
possibly due to hygiene.
Respiratory
respirations/cough/SOB
breath sounds all lobes ant/post
supplemental
oxygen/type/amount
trach/artificial airway/rhonchi,
rales (crackles), wheezes or
stridor supplemental O2-device,
amount
Patient’s Cough is congested and non-productive. RUL has crackles.
Decreased breath sounds in all fields. r/t to pneumothorax, COPD most
likely due to chronic cigarette use.
A & O x 4.
Oxygen Therapy: Nasal cannula, Adult 5 L/min. Humidifier/ Bubbler.
Cardiovascular
palpitations/chest
discomfort heart
sounds/extra sounds
rhythm regular/irregular
monitor strip interpretation
Telemetry monitored. Atrial flutter. Edema dependent, bilateral lower
extremities fluid overload. Patient feels right chest sided chest discomfort.
Peripheral Vascular
skin color
nail beds/cap refill/extremity
temp radial/dorsalis pedis
pulses
extremity edema-pitting vs
non-pit sacral edema, or
discoloration
Pitting 3+ in LLE/RLE. Mild edema non pitting in LUE and RUE. Due to fluid
volume overload, diabetic neuropathy, lack of mobility.
Gastrointestinal/Abdominal
characteristics of abdomen,
bowel sounds x4 quadrants,
tympany, bowel movement
abnormalities ostomy, gastric
tube, rectal tube feeding tube,
gastric tube (PEG)
Characteristics of abdomen, round and obese. Firm due to fluid volume
overload and poor diet. Bowel sounds normal x4. Normal bowel
movements/stools through colostomy.
GenitoUrinary
urine color/clarity/amount
pain/burn/discharge/reten
tion indwelling
cath/straight cath
bladder scan/retention
Light amber colored urine. No pain with discharge. Bladder scan 160ml.
Retention not present. Intermittent straight catheter.
Musculoskeletal
range of motion-neck/upper
and lower
extremities/deformities or
injuries/able to bear
weight/gait and devices and
level of assistance
RLE, LLE, RUE, LUE have increased weakness/ decreased sensation r/t
edema and Diabetic neuropathy. Unable to bear weight w/o rolling walker.
Integumentary/skin
assessment Skin color
pale or jaundice/temp/moisture
turgor/rash/lesions/bruises/wo
unds
Erythema on feet, peeling. Scaly lower extremity/bilateral. Related to
psoriasis and edema.
Areas of potential skin
breakdown/pressure sores
Sacrum is reddened but does blanch.
Nares and ears are at risk of skin breakdown due to prolonged nasal
cannula use.
Calf/thigh/arm DVT
assessment +/- Homan’s
sign
calf/thigh area with pain,
redness arm pain/redness
Negative Homan’s sign.
above IV site; swelling distal
to painful area
IV Sites/indwelling or
implanted lines or ports for
medications/fluids
assessment of site for redness,
tenderness, drainage and
description of dressing
No abnormal erythema or edema around PIV (right hand 22g). It is locked.
Dressing intact. Flushes without resistance.
Chest tube- no bleeding/ swelling. Air leak absent r/t pneumothorax. Water
seal drainage is below the patient. No evidence of bubbling.
Pain Assessment
type of pain-describe dull, sharp,
etc location/intensity using pain
scale
Dull aching pain on the right side of thorax.
PRIMARY PATIENT PROBLEM/NURSING DIAGNOSIS (problem “related to” and “as evidenced by”)
• Impaired gas exchange r/t decreased lung function from pneumothorax and COPD as evidenced by dyspnea, oxygen
through nasal cannula and abnormal ABG’s.
NG CARE: ENTER INDEPENDENT AND COLLABORATIVE INTERVENTIONS
Patient Specific Nursing Intervention(s)
ENTER SIX (6) OR MORE INTERVENTIONS
Rationale
FOR EACH INTERVENTION
1.
Checking vital signs- Temp, BP, Resp, Pulse,
mPAP every 4 hours.
Checking the patient’s vitals at consistent intervals helps
to identify complications before they become worse.
2.
Change IV line once every 24 hours due to
additives in infusion .
This will help prevent infection/ incompatibility of
drugs.
3. Measure the output of chest tubes and identify
characteristics of liquid.
This will help to determine if there is any abnormal
drainage where pneumothorax is.
4. Bladder Scan PRN- If volume is over 300cc then
straight catheter is implemented
This will help determine if patient is retaining urine r/t
neuropathy/neurogenic bladder
5. Dressings- Apply/ change PRN
This intervention promotes wound healing and limits
infection.
s.
6. Use of incentive spirometry once per shift
This will help prevent lung issues such as pneumonia
while also increasing the patient’s lung capacity.
I
Expected Outcome
AT LEAST TWO (2) OUTCOMES
1. The patient's lung function will improve.
2.
Patient’s edema in LLE & RLE will decrease.
Evaluation Strategy
FOR EACH OUTCOME
Patient oxygenation will decrease from 5 L to 3
L of oxygen through the nasal cannula. This is
while maintaining adequate SpO2 in the high
80s-90s.
Pitting 3+ in LLE/RLE will decrease to 1+ in the allotted
time.
ENTER RESOURCE(S) USED AS REFERENCE FOR NURSING DIAGNOSES, INTERVENTIONS, OUTCOMES
LISTED ABOVE IN APA FORMAT:
1. activity intolerance- Nursing Diagnosis & Care Plan. (2020, December, 6). Retrieved from
https://nurseslabs.com/4-anemia-nursing-care-plans/5/
LABORATORY AND DIAGNOSTIC TEST RESULTS RELATED TO NURSING DIAGNOSIS ABOVE
Date
Labs/Diagno
stics
Patient Results
Include normal
ranges for each
Related
Pathophysiology Any
pathology this test
may reveal or help
diagnose
Nursing Implications
CO2
Normal- 22-29 mEq/dL
Patient- 34
lungs can't remove
enough of the carbon
dioxide that the body is
producing.
Remain alert for complications
of respiratory acidosis such as
changes in resp, CNS, and
cardiovascular function.
Arterial
HCO3
Normal 22-26 mEq/L
Patient- 33
Kidneys are producing
more bicarb to
counteract the
respiratory acidosis.
The body is doing what it needs
to compensate for respiratory
acidosis. Rest, hydration and
proper oxygenation is needed.
The build up of positive
pressure in the pleural
space of the right lung is
not allowing for proper
expansion and
ventilation/perfusion.
This can lead to
atelectasis.
Monitor patient for signs of
increasing chest pain and or
dyspnea..
CT scan
Increasing tension in
pneumothorax with concern
for near or complete
collapse of the right lung.
SECONDARY PATIENT PROBLEM/NURSING DIAGNOSIS
(problem “related to” and “as evidenced by”)
● Acute pain r/t to the positive pressure in the pleural space as evidenced by grimacing and gaurding affected side.
NURSING CARE: ENTER INDEPENDENT AND COLLABORATIVE INTERVENTIONS
Patient Specific Nursing Intervention(s)
ENTER SIX (6) OR MORE INTERVENTIONS
Rationale
FOR EACH INTERVENTION
1.Checking the patient’s weight daily
Will help to see if the patient is depleting or retaining
fluid in third place. The reason why is that
pneumothorax can negatively impact hemodynamic
capabilities and even lead to heart failure.
2. Changing the linen. Checking/ making sure that
patient isn't on soiled linens.
For a patient who is in bed often due to immobility,
linen changes can promote comfort. Moreover, they can
help prevent nosocomial infections and skin breakdown.
3. Repositioning the patient every 2 hours.
This will help prevent pressure ulcers/ skin breakdown.
4. Keeping the head of the bed above 30 degrees.
This intervention will contribute to proper lung
expansion.
5. Auscultate breath sounds regularly.
This will help in identifying abnormal changes in
patients' lung condition. Provides a baseline for
pneumothorax resolution
6. Continuous ECG/ telemetry
This will help identify early cardiovascular issues due to
complications of the patient’s pneumothorax.
Expected Outcome
AT LEAST TWO (2) OUTCOMES
Evaluation Strategy
FOR EACH OUTCOME
Patient’s weight will be stable and not fluctuate
drastically
Weighing the patient and make sure she has not gained
2 pounds in a day and or 5 pounds in a week
Patient describes satisfactory pain control/management
The patient will state a pain level below 3 on a scale of
10. This is compared to a previous baseline pain
measurement of 8 out of 10.
ENTER RESOURCE(S) USED AS REFERENCE FOR NURSING DIAGNOSES, INTERVENTIONS, AND OUTCOMES
LISTED ABOVE IN APA FORMAT:
LABORATORY AND DIAGNOSTIC TEST
Date
daily
Labs/Diagnostic
s
Patient Results
Include normal
ranges for each
Related
Pathophysiology Any
pathology this test may
reveal or help diagnose
Nursing Implications
What patients may want
to know about why the
test is done; anything
nursing must know to
plan and provide care
Blood Urea
Nitrogen Daily-
Normal-around 6
to 24 mg/dL
Patient- 35 mg/dL
This lab helps determine
the kidneys functions and
can prevent acute kidney
injury.
Antibiotics and diuretics can be
hard on kidney and had
previously sent her into AKI.
(CT) coronary
angiogram
No pulmonary
embolism. Right
chest tube in place
and secure..
Pneumothorax can be
caused by a pulmonary
embolism and impact
cardiorespiratory
hemodynamics.
Thrombolytics would not be
necessary since no embolism is
present..
PHARMOCOLOGIC THERAPY
Use the chart below to list medications, both SCHEDULED and PRN
Medication Name and Dose/Route
(generic/trade)
Med Type and Reason for Medication
Administration
(brief reason/include what the med is
used for in this patient)
Insulin glargine (Lantus) injection 18 Units: dose 18 Units:
Subcutaneous: Daily
Long Acting
Helps to control patient’s blood sugar level due to
diabetes
Furosemide (LASIX) tablet 30 mg: Oral: Daily
Helps treat HTN or any Edema
Apixaban (ELIQUIS) tablet 4 mg: Oral 2 Times Daily
Treats and prevents blood clots, blood thinner
Atrial fib/atrial flutter
Albuterol (VENTOLIN) inhaler 1-2 Puff: Every 4 Hours As
Needed
relaxes muscles in the airways, widening them and
allowing more air to flow into the lungs
Piperacillin-tazobactam (ZOSYN) 4.2 g/50 mL–IV bag with
dextrose: Dose 4.2 g: 12 mL/hr: Intravenous: Every 8 hours
Combination of 2 antibiotics. It works by killing the
bacteria and preventing their growth.
PATIENT EDUCATION/DISCHARGE PLANNING:
INFORMATION NEEDED TO PROVIDE INDIVIDUALIZED NURSING CARE
Cultural Needs and
Implications
None
Management/Suppor
t Systems in Place
Patients Family is very close and they visit often. Recommendations for joining a
support group for those experiencing lung issues have been given
Financial
Issues/Concerns
none
Role Reversal Concerns
none
Other Issues
The patient needs to follow a prescribed diet for diabetes. This will help ensure she
does not increase her blood glucose to dangerous levels. This not only includes a
reduction in sugar consumption, but also sodium.
Plan of Care 2021/CG