Date: Feb 18
Patient: Mrs S
Room: 200 bed2
Age: 83
BCIT Level 2 Nursing Care Plan
Diagnosis: Choleycytitis
Treatments:
PMHx: CAD, AFib, COPD, PE, HTN, Anemia< SOB,
OSTEo,
Date of Surgery:
Diet: DAT
Type of Surgery: did not
do surgery
Activity: AAT
Medications: Lasix, Digoxin, Nitroglycerin patch,
Oxycodone
Simvastin, Vit. D, calcium carbonate,
PRN Medications: Acetaminophen
Potential Problems
What are the anticipated problems
for this patient and what is
potentially causing these problems.
(due to or related to)
Pulmonary Embolism ( History
of - so greater risk)
s an occlusion in vein caused by
a thrombus or embolism of
another substance
Steps in thrombus formation:
1. Platelets aggregate
( as a result of
turbulent flow and
endothelial injury in
valve pocket
2. WBC- adhere to
platelets
3. Platelets release
clotting factors and the
thrombus grows by
adding a clot
( RBCs and fibrin)
PE: DVT breaks loose travels
to right side of the heart and
into pulmonary artery
- occludes blood flow to the
part of the lung and impairs gas
exchange
- affected portion -> necrotic ->
VALIDATION PROCESS
ASSESSMENT
EVIDENCE
Wednesday PM – How will I assess each
problem?
*** palpation could dislodge causing
PE
PE:
*Assess for respiratory rate and depth
* Assess for increase WOB, SOB ,
use of accessory muscles
*Assess arterial blood gases (ABGs)
and note changes
Thursday PM – Data collected to
indicate a valid problem
INTERVENTIONS
Wednesday PM – What will I do for
each of the potential problems –
both nursing interventions and
medical interventions?
* position patient with proper
alignment
Change position Q2h –
EVALUATION/FOLLOW
UP
Thursday PM – What will I do Friday
for each valid problem
* If not contraindicated, sitting
position allows good lung
excursion and chest expansion
*facilitates movement and
drainage of secretions
*Airways opening by clearing
secretions
* assess characteristics of pain
*Assist with deep breathing and
coughing
*. Mobilize pt Q3h to prevent
blood stasis.
* coagulation cascade
- involves a series of chemical
reactions in which
fibrinogen(soluble) is converted
to fibrin(insoluble)
* assess acid-base balance
*Anticoagulant therapy
Assess for :
Warfarin
-Treatment of
thromboembolic
complications associated with
atrial fibrillation
Clotting Factors
= enzymes that cleave bonds
and expose active sites
- mainly produced in the liver (
some found in platelets and
endothelial cells
- circulate in the plasma in an
inactive form->activated ina
*Monitor O2 sat
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a cough that begins
suddenly, and may produce
bloody sputum (mucus):
significant amounts of
decreased oxygen delivery to
vital organs
- 90% comes from thrombi in
popliteal vein.
*factors contribute to DVT:
hypercoagulbility of the blood,
venous wall damage, stasis of
blood flow
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visible blood or lightly blood
streaked sputum (phlegm)
sudden onset of shortness of
breath at rest or with exertion
splinting of ribs with
breathing (for example,
bending over or holding the
chest)
fainting
dizziness
sweating
anxiety
rapid breathing
rapid heart rate
chest pain:
Diagnostic Tests for PE:
Electrocardiogram
ultrasound examination of the legs, or
a lung perfusion scan
-treatment of venous
thrombosis, pulmonary
embolism
Action: Coumarin
anticoagulants inhibit
synthesis of prothrombin
- interfering with action of
vitamin K
Intrinsic Pathway (contact
activation pathway)
- occurs more slowly
-All components are within the
blood
-initiated when factor XII
(clotting factor) is activated by
the contact of blood with
subendothelia collagen damage
or an artificial surface
Thrombin is the final activated
clotting factor and converts
fibrinogen to fibrin
*CT angiogram is a type of computed
tomography (CT) scan. It is fast,
noninvasive, and fairly accurate,
particularly for large clots. In this test,
contrast material is injected into a
vein. The contrast material travels to
the lungs, and a CT scanner generates
images of blood in the arteries to
determine if a pulmonary embolism is
blocking blood flow. A CT angiogram
is the imaging test most often used to
diagnose pulmonary embolism
Diagnostic tests
Spiral CT angiogram:
pulmonary nodules are well
evaluated because breathing
misrepresentations are
eliminated.
- continuously obtains images as
the patient is passed through the
gantry.
V/Q Scan:
Is used to identify defects in
blood perfusion of the lung in
patients with suspected PE.
Perfusion Scan:
1.Patient is given a peripheral
IV injection of
radionuclidetagged MAA
(macroaggregated albumin)
2. While the patient lies in the
appropriate position, a gamma
ray detector is passed over the
fixed sequence
- the activated clotting factor
acts on the next precursor
- because a single activated
product can act on many
precursors-> amplification
- must reach a certain
concentration before clotting
can occur
_ there are two pathways that
lead to the activation of clotting
factor X and the synthesis of
prothrombinase ( factor Xa)
! Extrinsic pathway ( tissue
pathway)
- primary pathway
-occurs rapidly ( within
seconds of trauma)
-initiated by tissue factor (
extrinsic to the blood) (–
protein that is the primary
cellular initiator of blood
coagulation)
- on the surface of
subendothelial cells (
fibroblasts)
- released by damage
endothelial cells
patient and records radionuclide
uptake on Polaroid or x-ray
film.
3. patient is placed in a supine,
prone, and various lateral
positions, which allows for
anterior, posterior and lateral
and oblique views
Ventilation Scan
1.Pt. breathes through a closedsystem mask with a mouth
piece. A radionuclide tracer is
then administered into the
system.
Ultra sound
X-Ray
Atrial Fibrillation (ACTUAL)
- is the result of disorganized
current flow within the atria.
Fibrillation interrupts the
normal contraction of the atria.
- is characterized by rapid,
chaotic atrial depolarization
from a reentrant pathway.
At extremely rapid rates the
entire atrium may not be able to
recover from one depolarization
wave before the next one
begins, resulting in mechanical
and electrical disorganization of
the atria without effective atrial
contraction.
- The AV node is bombarded
with more impulses than it can
conduct so a rapid ventricular
response comparable to the
atrial rate cannot occur.
- Because of the atrial
disorganization the “atrial kick”
is lost -> decreases cardiac out
put by 30%.
- With increasing ventricular
rates allowing less filling time,
Ausculate the heart for tachycardia (
greater than 100beats) and
bradycardia ( less than 60 beats)
* assess for signs of reduced cardiac
output: rapid, slow, or weak pulse,
hypotension, dizziness, syncope,
SOB, restlessness, chest pain, fatigue
* Stimulants increase the
automaticity of the heart which
can precipitate dysrhythmias
1. Deliver heart medications.
pt. is on
Warfarin
2. Maintain fluid balance. Input
= output. If input increases and
output is decreased pulmonary
or peripheral edema can occur.
3. Allow environment for
physical and emotional rest as
stress can increase cardiac
demands. This also reduces
oxygen demands.
cardiac output declines even
further and may result in
dyspnea, angina pectoris, heart
failure, and shock
-may be a pulse difference
between apical and radial
pulses.
* blood pools in the atria
because of lack of adequate
contraction of atrial
appendages. Pooling blood is
prone to clot, forming a mural
thrombus, which increases the
risk of cerebral and peripheral
vascular emboli>
COPD ( ACTUAL)
COPD
- Inflammation and fibrosis of
the bronchial wall, hypertrophy
of the submucosal glands and
hypersecretion of mucus and
loss of alveolar tissue and
elastic lung fibers.
Inflammation and fibrosis of the
bronchial wall, along with
excess mucus secretion,
obstruct airflow and cause,
mismatching of ventilation and
perfusion. Destruction of
alveolar tissue decreases the
surface area for gas exchange,
and the loss of elastic fibers
impairs the expiratory flow rate,
increasing air trapping, and
predisposes to airway collapse.
1.Ausculate lungs after coughing as
needed to note and document
significant change in breath sounds:
*Decreased or absent lung sounds
-indicate presence of mucous plug or
other major airway obstruction
*presence of fine crackle-may
indicate cardiac involvement or
secretion trapping
*wheezing
-indicates increasing airway resistance
*course sounds
-indicate presence of fluid along
larger airways
Position head of bed in upright
and high Fowler’s position
- favors lung expansion; the
diaphragm is pushed downward.
If patient is bedridden, turning
from side to side at least Q2h
promotes better aeration of all
lung lobes
2. Assess for change in resp rate and
depth
-rate and rhythm changes are early
signs of resp compromise
* Teach patient deep breathing
techniques
3Assess characteristics of or changes
in secretions: consistency, quantity
and color
4. Note any color in changes in lips,
buccal mucosa, nail beds
- cyanosis occurs when at least 5g of
*Assist patient with
coughing, deep breathing,
and splinting
- improves productivity of
cough
*Administer low- flow oxygen
therapy as indicated (e.g.,
3L/min by nasal cannula) . If
insufficient , switch to highflow o2 apparatus (Venturia
mask) for more accurate oxygen
delivery
Consult respiratory
Encourages a more complete
exhalation
COPD patients who chronically
retain carbon dioxide depend on
“hypoxic drive” as their stimulus
to breathe. When applying
oxygen, close monitoring is
imperative to prevent unsafe
increases in the patient Pa O2
which could result in apnea.
- reduce airway resistance, treat
infection, and facilitate secretion
haemoglobin are desaturated
5. Assess hydration status: skin
turgor, mucous membranes, tongue
-Airway clearance is impaired with
inadequate hydration and subsequent
secretion thickening.
6. Monitor pulse oxygen saturation
and ABGs
-hypoxia can result from increased
pulmonary secretions and resp.
fatigue
Acute Pain
(due to gallbladder stone, c/o
pain in abdominal area)
Acute pain is frequently
associated with anxiety and
hyperactivity of the
sympathetic nervous system
Pain has sensory and
emotional components
Gate Control TheoryMelzack
The interplay among these
connections determines
when painful stimuli go to the
brain:
1. When no input comes in,
the inhibitory neuron
prevents the projection
neuron from sending signals
to the brain (gate is closed).
2. Normal somatosensory
input happens when there is
more large-fiber stimulation
1. assess pt pain behaviour.
(grimacing, guarding, wincing,
avoiding movement)
2. assess pt pain level on a scale
of 1-10 & LOTARP pain Q1hr
3. assess pt’s last dose of
analgesic and frequency
4. Monitor autonomic responses
(diaphoresis,  HR,  RR, change
in BP, nausea, pallor, pupil
dilation)
5. assess pt knowledge or
preference for the array of pain
relief strategies available
6. evaluate pt response to
meds/theraputic interventions
therapist for chest
physiotherapy and
nebulizer treatment
*Administered bronchodilators,
expectorants, anti-inflammatory
(steroids) and antibiotics, as
ordered
* Incentive Spirometer –
improves deep breathing and
prevents atelectasis
10x hour
*Pace activities for patient with
reduced energy
1. Help pt into a comfortable
position. Provide pt with a
heating pad or warm blanket
to help alleviate pain.
2. administer appropriate
analgesic if pt is do for next
dose. (Refer to pops list and
WHO pain scale). Also
educate pt to report pain,
especially if it is not
controlled.
3. evaluate the pt’s response
to pain and medication and
medications or therapies
aimed at relieving pain.
(Q1hr)
4. provide rest periods to
facilitate comfort, sleep and
relaxation. Can also provide
distractions such as
conversation, tv,
5.Assess and document the
intensity of the pain and each
new report of pain at regular
intervals (systematic ongoing
assessment and
documentation provide the
direction for pain treatment
plans and adjustments based
removal
(or only large-fiber
stimulation). Both the
inhibitory neuron and the
projection neuron are
stimulated, but the inhibitory
neuron prevents the
projection neuron from
sending signals to the brain
(gate is closed).
3. Nociception (pain
reception) happens when
there is more small-fiber
stimulation or only small-fiber
stimulation. This inactivates
the inhibitory neuron, and the
projection neuron sends
signals to the brain informing
it of pain (gate is open).
on the pt’s response
1.Epidural
Need to explain
2. PCA
Need to explain
Discharge planning
How is she coping?
What type of support does
she have?
Does she have a
supportive friends that can
come and help with
household chores, making
meals when she is at
home?
Does she have someone
to take her to all the
appointments
Does she have visitors?
Does she have a
thermometer at home?
Where does she live?
Whom does she live with?
Meals on Wheels (Vancouver)
604-732-7638
Community nurseVancouver -604-263-7377