Medications
(see attached)
IV Sites/Fluids/Rate
Right TL IJ
NS@ 30hr
Student Name: Kim Posey
Age: 56
Gender: F
Client Initials: M.M
Room # ICU 24
CODE Status: Full Code
Date: 2-4-13
Admit Date: 1-30-13
Allergies: ACE Inhibitors, PCN
Diet: FEEDING TUBE PEPTAMEN BARIATRIC 40ml/HR
Activity: bed rest
Braden Score : 17
Monitoring: Invasive/NonInvasive State specific
monitoring device and
specific values with each
device
5 Lead EKG (see attached
paper) PQRST, heart rate and
rhythm,
VENT
Vent Mode: AC
FiO2: 60
TV: 600
RR:16
PEEP: 7.5
*Patient was extubated @
945am
ECG Interpretation
(see attached)
Chief Complaint: Difficulty in breathing
Admitting Diagnosis(es): Respiratory Failure, COPD, HAP
State lab values and identify
trends.
141 │105 │47 (H) 176 (H)
4.4 │23 │ 1.460 (H)
___8.2
7.7 (L)
___Mg 14.0(H)
264
PO4
27.0 (L)
State other appropriate lab
results
PH- 7.31(L)
PCO2- 50.9 (H)
HCO3- 25.3
State diagnostic test results

Medical/Surgical Diagnosis(es): Respiratory Failure and Chronic
Obstructive Pulmonary Disease




1.Describe the patient’s condition, including signs/symptoms that
led to this
Admission: The patient was brought into hospital from a nursing
home with c/o trouble breathing. When ambulance arrived at facility
the patient was alert c/o trouble breathing and coughing. They know
WBC increased D/T HAP,
UTI
H&H decreased- dx of
anemia
BUN/CREAT: due to
patient having stage III
kidney disease, CHF,
ABGS’ compensated
Respiratory acidosis
GLUCOSE: patient is
diabetic
(Pagana & Pagana, 2011)
Past Medical/Surgical History
Relevant to this admission
CHF
Bronchitis with chronic
hypoxic and hypercapnic
respiratory failure,
Chronic UTI
Hypercapnic encephalopathy
HTN
Multiple Sclerosis
Seizure disorder
Kidney disease stage III
Morbid Obesity
Depression
HX of 5 Trach’s
Anemia
this patient from past that when this happens she deteriorates fast. In
route to the hospital her breathing became worse and became sleepy.
Patient stats were in the 60’s and the patient was intubated in the
emergency department. The patient is currently on a ventilator and
sedated, at this point the patient is stable on vent, she continues to be
sedated and in soft wrist restraints. The sedation medication was turned
down and the patient is becoming more awake. The Respiratory doctor
was in to see patient and decided to extubated patient. The doctor was
expected to put in a trach because the patient has a history of trach’s.
Once patient was extubated, she was placed on 50% aerosol mask at 7
liters, and was titrated down to 4liters and switched to nasal cannula.
2. Briefly describe the pathophysiology related to the patient’s
diagnosis and current medical/surgical condition.
The patient has an extensive respiratory history, bronchitis with
chronic hypoxic and hypercapnic respiratory failure, history of 5
trach’s, and the patient has MS. Since MS affects muscles, it will affect
the diaphragm which would cause the patient to be unable to take in
deep breaths, accessory muscles become weak and lungs less
compliant. Also the patient being morbidly obese can cause restriction
to breathing, diaphragm, cannot expand. Unable to get a sufficient
amount of O2, the patient is retaining more CO2 which cause
respiratory acidosis which can cause respiratory failure. Which can
flare up COPD and also leaving the patient vulnerable to getting
pneumonia, also pneumonia could have cause the respiratory failure
(Black, J.M., & Hawks, J.H., 2009)
3. Describe the patient’s head to toe assessment findings and
explain how they relate to the pathophysiology. Include the vital
signs. Patient is morbidly obese, pale, rhonchi throughout lungs;
patient on vent is starting to be more alert with decreasing profonol.
She has weakness in extremities, foley cath draining clear yellow urine;
bowel sounds x4, PERRLA. She understands questions and can shake
her head yes or no, has TI LJ in right neck, EGT placed. Patient being
morbidly obese can cause breathing restriction, rhonchi throughout
lungs is from Respiratory failure and from CHF, weakness is from the
MS, she is wheelchair bound when at SNF, patient is pale from being
anemic. Once off vent and put onto mask and then nasal cannula
Treatments/ Medical and Nursing
Interventions
Foley Cath
Turn Q 2
Strict I&O
Daily WT
Albuterol and Atrovent Q6hrs &
PRN
Barrier Cream
Bilateral Soft Wrist
Blood Transfusion @ 1120
patient is noted to have dyspnea which is related to respiratory failure,
COPD and pneumonia,
4. Integrate the current laboratory, diagnostic test results,
hemodynamic parameters medications, medical and nursing
interventions, and other treatments into the pathophysiology and
explain how it is affecting this patient’s outcome/current condition.
****Please see attached paper*****
Primary Nursing Diagnosis with
Relational Statement
Impaired Gas Exchange R/T altered
oxygen-carrying capacity of blood, having
respiratory failure
Definition (State definition and source)
Unable to have CO2 and O2 gas exchange
(Doenges, Moorhouse, & C, 2009)
AEB: Defining characteristics specifically
exhibited by your patient that support
primary nursing diagnosis
Patient has history of Bronchitis with
chronic hypoxic and hypercapnic
respiratory failure, COPD, Anemia,
Patient in Compensated Respiratory
Acidosis, patient on vent
Short Term Goal Relevant to Nursing
Diagnosis Patient will demonstrate
improved ventilation by end of shift
Outcome Criteria (Must be specific and
measurable)
Patient will demonstrate
improved ventilation by end of
shift
 Met- patient was breathing
over vent and vent was
pulled and put onto 4L NC
Patient ABG’s will come back into
normal limits by end of shift
 Not Met- patient ABG’s are
from the ED, no new
ABG’s have been drawn as
of yet
Patient will do cough and deep
breathing exercises Q1 hr
 Met, encouraged patient to
do coughing and deep
breathing exercises,
6 Nursing Diagnosis with Relational
Statement
1. Anxiety R/T difficulty breathing
2. Fatigue related to infection
secondary to MS
3. Risk for dysfunctional ventilator
weaning process related to
respiratory failure
4. Activity intolerance R/T MS and
respiratory failure
5. Risk for fluid volume excess
related towards chronic kidney
disease stage 3
6. Impaired mobility R/T MS
explained importance of
these exercises
Patients Pulse Ox stats will stay
above 93% throughout the rest of my shift
 Met, patient pulse ox was
mid 90’s
Identify nursing interventions that you implemented with this patient. Evaluate patient progress towards achieving outcome criteria
as a result of nursing interventions.
 Monitor Client on Vent to see if patient is breathing on own and update doctor on patient status
 Patient was breathing over vent and vent was pulled
 Monitor respiratory rate, depth, and effort Alveolar hypoventilation and associated hypoxemia lead to respiratory failure
 Once pt. was off vent respiratory status was monitored closely respirations were around 20, patient did have dyspnea
at times
 Restrict use of hypnotic sedatives or tranquilizers. Respiratory depression and CO2 narcosis may develop
 Patient propfonol was weaned down
 Administer Oxygen as indicated it helps aid in hypoxemia
 Once patient was weaned off vent, a 50% aerosol mask at 7 liters was put on to patient and weaned down to 4 L on
nasal cannula
 Encourage and assist with deep-breathing exercises, turning and coughing to help improve lung ventilation and reduce or
prevent airway obstructions associated with accumulation of mucus.
 Encouraged patient with deep breathing exercises and use of IS, turned Q2hrs
(Doenges, Moorhouse, & C, 2009)
Secondary Nursing Diagnosis with
Relational Statement
Ineffective air way clearance related to
inability or ineffective cough
Short Term Goal Relevant to Nursing
Diagnosis
Maintain patent airway with breath sound
clear during my shift
Definition (State definition and source)
Outcome Criteria (Must be specific and
measurable)
Unable to effectively clear airway
(Doenges, Moorhouse, & C, 2009)
AEB: Defining characteristics specifically
exhibited by your patient that support
primary nursing diagnosis
Being on vent
Having to be suctioned
Has anxiety
Rhonchi throughout lungs
What I Would Do Differently
Ask more questions about the vent settings
Got more hands on with the suctioning
Ask how they determine when and how to
wean a person off the ventilator
Ask the doctor to see if he wanted a new
ABG after patient had been off ventilator
Patient will be able to cough out secretions
by end of shift
*Met, after ET was removed patient was
coughing and bringing up sputum
Patient O2 stats will stay above 93%
throughout shift patient O2 stats ranged in
mid 90’s
Patient will understand the importance of
clearing airway by end of shift
*Patient understands that she needs to keep
her airway clear from secretions
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-obstruction may be caused by accumulation of secretions
 Patient was checked on frequently lungs were asculated
Monitor ET tube placement- tube may slip into right main stem bronchus
 Tube placement checked
Encourage Cough and deep breathing exercises- help cough up secretions
 Patient doing coughing and deep breathing exercises
Perform suctioning on as a needed bases- many traumatize air way and mucosa
 Patient was suctioned as needed
(Doenges, Moorhouse, & C, 2009)
Current lab work shows that the patient is in compensated respiratory acidosis which is leading
to her respiratory failure. She also has HAP which could have been the precursor to the patient
for going into respiratory failure. These two things are making it difficult for the patient to
breathe and to have adequate perfusion in the lungs. The patient had to be placed on a vent to
stabilize the patient and get the respiratory system under control. The breathing treatment the
patient is receiving is to help aid in opening up the alveoli to help improve ventilation. The
patient is also receiving the antibiotic to help with the pneumonia. Blood transfusion is to help
bring up the patient blood count and with that will help carry more oxygen throughout the body.
The nursing intervention applied towards this patient is for improving the patients
breathing and ventilation. The interventions are meant to help to make sure the patient is getting
enough oxygen in the body.
Since the patient started to breath over vent, the Respiratory doctor decided to take
patient off the vent. After taken off the vent the patient was put on a 50% aerosol mask at 7 liters
and was titrated down to 4 liters nasal cannula by the end of my shift, Patient pulse ox was
ranging in mid 90’s good enough to keep patient on nasal cannula. Since the vent was helping
the patient breath it was able to stabilize her breathing more efficiently and by that, they were
able to wean her off the vent. There was no current ABG’s ordered only ABG was from the
patient was in the ED.
With the patient having MS this also affects the respiratory system because decrease
muscle strength and inability full expand diaphragm to breathe in, and breathe in the O2 needed.
Also at the nursing home the patient is wheel chair bound because of the MS. Since patient is
diabetic also, her blood glucose can become out of control because of stress, infection and
respiratory status.
References
Black, J.M., & Hawks, J.H. (2009). Medical-Surgical Nursing: Clinical Management for
Positive Outcomes (8th ed.). St. Louis: Saunders Elsevier.
Doenges, M. E., Moorhouse, M. F., & C, M. A. (2009). Nursing Care Plans Guidelines for
Individualizing Client Care Across the Life Span. Philadelohia: F.A Davis Company.
Pagana, K., & Pagana, T. (2011). Mosby's Diagnostic and Laboratory Test reference. St. Louis:
Elsevier Science Health.
Skidmore-Roth, L. (2011). 2011 Mosby's Nursing Drug reference. St. Louis: Elsevier, Mosby.