Medications
(see attached)
IV Sites/Fluids/Rate
Triple lumen PICC rt upper arm
D5NS 20 ml at 20
NS @ 10 ml/h KVO
Solumedrol 4 ml/h
Monitoring: Invasive/Non-Invasive
Ventilator-system control
TV: 350
Rate: 22
Vent: 40
Telemetry: non invasive
Student Name Mellanie Hopkins
Age 57
Gender Female
Client Initials S.S.
Room # 1097
Date
9/16/09
Admit Date 8/17/09
CODE Status FULL
Diet Enteral Fibersource
Allergies NKA
Activity Bedrest
Braden Score 11
Chief Complaint: SOB
Admitting Diagnosis: cardiac arrest, respiratory failure
Medical Diagnosis: CHF, respiratory failure secondary to cardiac arrest, anemia secondary to
renal failure
Pulse Ox-non invasive 97-100%
ECG Interpretation
(see attached)
Normal Sinus Rhythm
Past Medical/Surgical History
Relevant to this admission
2 cardiac arrests
Respiratory failure
Type 2 DBM
Chronic kidney disease
Glomerulonephritis
COPD
CAD
Dyslipidemia
Former smoker
Congestive heart failure is a condition which body tissues become congested due to the heart’s
inability to pump a sufficient amount of blood to meet the tissue’s metabolic needs. CHF can
be caused by decreased cardiac output with fluid accumulation in the body tissues accompanied
by increasing ventricular pressure. Manifestations noted were adventitious lung sounds, cough,
edema, fatigue and high BUN, Creat, and BUN/Creat lab readings. BUN and creatinine are the
primary tests used to check how well the kidneys are able to filter waste products from blood.
Pulmonary edema is where fluid accumulates in the interstitial spaces and alveoli interfering
with gas exchange. A cause is inadequate contractility of the left ventricle as in CHF. When
CO drops, the heart is not able to circulate fluid and blood pools in the pulmonary circulation.
Lower extremity edema fluid returns to the vascular compartment and is redistributed to the
pulmonary circulation because the heart is unable to pump effectively. Manifestations noted
included dyspnea, tachypnea, wheezing, anxiety, confusion, and a chest x-ray showed bilateral
pleural effusion likely reflecting pulmonary edema. Respiratory distress causes increased work
of breathing, rapid breathing with high respiratory rates. An ineffective cough compromises
airway clearance by preventing mucus from being expelled. As fluid accumulates, abnormal
breath sounds such as rhonchi and wheezes can be heard. Labs indicated a high A/G ratio
which helps screen for and diagnose kidney disease. Cardiac arrest is a cessation of breathing
and circulation due to the loss of cardiac pump function. The most common causes of cardiac
arrest are ventricular tachycardia and ventricular fibrillation due to congenital heart disease,
MI, and heart failure. Patient was receiving ventilation, non invasive telemetry, blood pressure
support, and medication decreasing heart workload and oxygen demand. Anemia is the
reduction in the number of RBCs or the quantity of hemoglobin and hematocrit as seen in
S.S.’s labs. The manifestation of anemia noted could have been related to decreased oxygen
delivery to the tissues.
Lab values 9/15/09
150 │ 120 │ 64
4.0 │CO2 │ 1.23
435
8.1Ca
___Mg
2.3 PO4
126
9.4
12.9
31.7
HGB 9.4L Anemia, nutritional deficiency,
renal disease
HCT 31.7L Anemia, vitamin or mineral
deficiencies, recent bleeding
RBC 3.3L Iron deficiency, anemia, chronic
illness, renal failure, overhydration, dietary
deficiencies
PLT 126L Lovenox therapy, kidney disease,
anemia
WBC 12.9H Infection, stress, inflammation
Phos 2.3L Hyperinsulinism, inadequate
dietary ingestion of phosphorus
Na 150H IV fluids, free body water loss
GLU 435H DM, stress response, diuretic
therapy
BUN 64H CHF, renal disease, infection, MI,
DM
CREAT 1.23H Renal disease,
glomerulonephritis, CHF, diabetes
BUN/CREAT 52H Renal disease, CHF
Albumin 1.4L Glomerulonephritis
A/G ratio 3H Inflammation, respiratory
distress,
Calcium 8.1L Infections, renal failure
Chest x-ray bilateral air space disease with
bilateral pleural effusion likely reflecting
pulmonary edema.
Treatments
Medical and Nursing Interventions
Relevant to this admission
BS q2h
Turn q2h
Decubitus cream applied to affected
area qs.
HOB elevated
Suctioning prn
Trach care qd
N/G rt nare for enteral feeding and po
meds 70 cc/h
Foley cath care
Rectal thermometer with cooling
blanket parameters T>102
Primary Nursing Diagnosis with Relational Statement
Short Term Goal Relevant to Nursing Diagnosis
6 Nursing Diagnosis with Relational Statement
Ineffective airway clearance R/T artificial airway in
trachea.
Patient will be free of aspiration during my shift.
Risk for aspiration r/t artificial airway in trachea.
Impaired skin integrity r/t 3 coccyx pressure ulcers and
bilateral tears on skin, LL 2+ edema.
Definition – State in which a person experiences a threat
to respiratory status r/t inability to cough effectively.
Outcome Criteria (Must be specific and measurable)
Carpenito-Moyet, L.J. (2008). Nursing Diagnosis: Application
to Clinical Practice (12th ed). Philadelphia, PA:
Lippincott.
Patient had effective airway clearance AEB secretions
removed by suction and trach care during shift.
AEB: Defining characteristics specifically exhibited by
your patient that support primary nursing diagnosis
Tracheostomy
Copious secretions
Ineffective cough
Immobility
Respiratory rate >28
Bilateral rhonchi and wheezes
Excess fluid volume r/t peripheral 2+ edema.
Patient had adequate gas exchange AEB pulse ox >97%
during shift.
Risk for infection r/t intubation, PICC line, tube feeding,
increased hospital stay dating back to 8/17, open wounds
and debilitated condition.
Pain r/t nonverbal facial expression of discomfort.
Patient had no indications of infection AEB having clean,
dry trach site.
Risk for impaired gas exchange r/t respiratory rate >28,
confusion, copious secretions.
Patient demonstrated no rapid weight changes AEB
weight remained the same throughout the week. (75kg)
Identify nursing interventions that you implemented with this patient.
Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.
Assess airway patency q2h to check for obstruction caused by secretions. Suctioned prn.
Auscultated bilateral breath sounds q3h. Rhonchi and wheezes noted at each assessment.
Kept patient HOB elevated to reduce aspiration.
Turned patient q2h due to immobility.
Applied ET mix decubitus cream qs on pressure ulcers. No change in size, drainage noted.
Assessed daily weight and compared with previous weight to monitor excess fluid. No changes noted.
Assessed N/G tube location and checked residual.
Darvocet administered per order po via N/G due to patient’s indication of pain. Reassessed pain level and pain denied.
Mouth care performed q2h.
What I Would Do Differently
I would have liked to have more prior experience with
ventilators, trachs, and N/G tubes so I could have been
better equipped to take care of Shirley. I am a visual
learner. I would also have talked to Shirley more
throughout the shift besides introducing myself and
keeping her informed on what I was doing because she
was responsive at certain times. I would have liked to
have been able to thoroughly review Shirley’s chart to get
a better understanding of what she had been going
through the past month while hospitalized.