Medications
(see attached)
IV Sites/Fluids/Rate
Left Hand: 18
½ NS @ 80 cc/hr
and
Vancomycin @ 166 cc/hr
State lab values and identify trends.
Student Name _____Jessica Thompson____ Client Initials ___MLV___ Date __1/30/12___
Age __43___ Gender __M___ Room # __24__ Admit Date __1/29/12___
1/30/12
143 │ 112H │ 26
5.4H │21 │ 2.21H
105
CODE Status ____Full____ Allergies ___NKA____
Diet ___Clear Liquid___ Activity ___Up As Tolerated___
Braden Score ___16___
Monitoring:
___Ca
___Mg
PO4
10.3
10.5L
317
32.6L
State other appropriate lab results
Chief Complaint/Admitting Diagnosis(es):
External/non-invasive
5 lead, pulse ox, BP cuff
Shortness of breath, cough with clear phlegm and shaking chills. Labored breathing with
wheezing. Reddened right lower extremity (calf).
Medical/Surgical Diagnosis(es):
Respiratory failure with left lower lobe Pneumonia with left-sided pleural effusion. Sepsis with
acute renal failure.
ECG Interpretation
(see attached)
1.) 43 year old male with morbid obesity was brought to the emergency room because
of a one week history of SOB and clear productive cough. Pt c/o unusual labored
breathing with walking a flight of stairs and being unable to catch his breath at which
time an ambulance was called to his home.
2.) The “development of acute pneumonia implies a defect in host defenses, a
particularly virulent organism, or an overwhelming inoculation event” (Urden, 2010,
p.614). In this case, the pneumonia was community-acquired; possibly related to
Streptococcus pneumoniae, Legionella spp., Haemophilus influenza, or respiratory
viruses for example, which will be determined through the pending blood culture.
Sepsis is a complex over-response of the immune system in response to an infection.
“Sepsis is the most common cause of acute kidney failure in the critically ill; by
creating hemodynamic instability and reduced perfusion to the kidneys” (Urder,
2010, p. 798).
3.) A head to toe assessment preformed 1/30/12 found the following:
Vitals: HR- 160(increased heart rate is common in patients with sepsis, as the body is
compensating for decreased blood pressure), RR- 30 (a common manifestation in
these patients related to the lungs compensating for their decreased function), BP124/66(although this is an acceptable blood pressure, pressures are lowered with
sepsis), T- 99.0F (elevated temperature points to the presence of infection)and pulse
1/29/12: ABGs- metabolic acidosis
PH: 7.29L
pCO2: 38.8
pO2: 73L
bicarb: 18.3L
base: -7.6L
O2 saturation: 92.5%
1/30/12: Renal Labs
AST: 15
ALT: 10L
State diagnostic test results
1/29/12:PCXR- complete
opacification of lower half of left
hemithorax consistent with pleural
effusion. Atelectasis and
consolidation; right lung is clear;
enlarged heart –cardiomegaly.
1/29/12: Blood Culture- results
pending
1/30/12: Duplex scan of bilateral
lower extremities- no echogenic
Past Medical/Surgical History
Relevant to this admission
Obstructive sleep apnea
Hx of smoking- quit 10 years ago
NIDDM
morbidly obese
HTN
oximetry- 98% with NC 14Lpm(Increased need for oxygen supply relates to the
decreased function of lungs to provide the blood stream with adequate amounts of
oxygen). Pain is reported as 5/10: general all over and lower back (this may be related
to the acute kidney failure).
A&Ox3, pt c/o feeling “woozy” with standing(disorientation and hypoxemia related
to both pneumonia and sepsis can lead one to feel dizzy with position changes), all
extremities strong and equal.
Pt states he is normally confined in his home due to his anxiety related to
agoraphobia.
PERRLA, normal sinuses and glands, no drainage from ears, nose, eyes.
Mucous membranes pink and moist. Skin is warm and dry with normal capillary refill
and turgor. Lower extremities with bilateral edema pitting +2(septic shock increases
membrane permeability, allowing for fluid moving into the third space). Redness
noted on entire length of posterior right lower extremity(discomfort may be related to
the increased fluid and stretch of the skin of the edematous extremities) with little
associated pain.
Heart sounds are rhythmic but tachycardic(as previously noted, heart rate increases
to compensate for decreased blood pressure with sepsis)
Lungs are clear, equal but diminished (Alterations in lung function relate to abnormal
lung sounds).
Abdomen is large and firm with hypoactive bowel sounds. LBM was 1/28/12.
Voiding pattern q3hr.
4.) With sepsis, “ABG values reveal metabolic acidosis”, as seen in this case (Urden,
2010, p. 994), as well as hemodynamic changes such as increased WBCs. Metabolic
acidosis relates directly to the decreased renal functioning; as kidney perfusion is
changed, urine output is altered and laboratory results in turn are abnormal(decreased
renal labs and abnormal ABG results). Blood and sputum cultures will reveal what
factor has caused this medical condition, however, until those results are revealed a
resuscitation bundle was administered. This bundle “measures serum lactate, provides
broad spectrum antibiotics, maintains or improves blood pressure with fluids and
vasopressors” (Urden, 2010, p. 994). At this time broad spectrum antibiotic are being
given to help fight any organism that is causing the infection; as specific laboratory
details are noted medications can be narrowed to fight the exact organism. A focus
for this patient is preventing further sepsis and sepsis related shock. Nursing
interventions include administering prescribed fluids and medications, promoting
comfort and emotional support, monitoring for further complications, practicing and
most importantly, teaching hand washing. As noted by the patient, he lives a more
secluded and isolated lifestyle, because of this, he had not received vaccinations,
anytime spent out in the community or in conversing with his family allowed him to
contract a microorganism leading to pneumonia and sepsis; hygiene and hand
filling noted.
1/30/12: Chest Ultrasound
1/30/12: Sputum Culture and
Sensitivity- results pending
Treatments/ Medical and Nursing
Interventions
1/29/12: Bipap 2hr on/2hr off 40%
and prn 16/11 titrate O2 to keep
>92%, nonrebreather mask 55%
alternate with NC 14Lpm.
1/29/12:aerosol albuterol 2.5mg
q6hr and q2hr prn.
1/29/12:thoracentesis of left pleural
effusion- removal of 2640mL
pinkish milky colored pleural fluid.
This fluid shows markedly elevated
triglycerides, suspicious for
chylothorax
1/29/12: ACHS blood sugar checks
1/29/12: consultations with
infectious disease and pulmonology
washing could have prevented him from becoming ill.
Chest radiography, sputum and blood cultures, chemistry panel, and ABG are
common tests relating to pneumonia. Treatment of pneumonia includes the use of
antibiotics, oxygen therapy and possible mechanical ventilation. In this case, the
patient has been ordered bipap therapy alternated with oxygen flow via nasal cannula,
as well as aerosol treatments to help open the airway. This patient also underwent a
thoracentesis to remove excess pleural fluid. Nursing interventions once again,
include practicing and promoting the prevention of spreading infection, as well as
positioning the patient in comfortable ways allowing for adequate ventilation and
exercises to improve lung function, such as coughing and deep breathing and use of
the incentive spirometer.
Primary Nursing Diagnosis with Relational Statement
Short Term Goal Relevant to Nursing
Diagnosis
Ineffective breathing pattern related to decreased lung expansion and function.
6 Nursing Diagnosis with Relational Statement
1.
The client will demonstrate improved gas
exchange in the lungs as seen in improving
ABG results and respirations of normal levels
(12-20 breaths per minute) within 24 hours of
admission
2.
3.
4.
During my shift, the patient’s oxygen
saturation remained in normal levels, his
respirations remained high but were lower
than previously noted.
5.
6.
Definition (State definition and source)
Ineffective breathing pattern: “The state in which an individual experiences an
actual or potential loss of adequate ventilation related to an altered breathing
pattern” (Carpenito-Moyet, 2006, p.263).
Outcome Criteria (Must be specific and
measurable)
1.) The client’s ABGs will be within a
normal range within 24 hours of
hospitalization: Goal not met,
Activity intolerance related to morbid
obesity and decreased lung function
Excess fluid volume related to
decreased renal function
Impaired gas exchange related to
decreased lung function
Social isolation related to fear of
crowds
Ineffective tissue perfusion related to
decreased lung function and
sedentary lifestyle
Knowledge deficit related to current
health status. AEB DM, obesity,
HTN, acute renal failure, sepsis
AEB: Defining characteristics specifically exhibited by your patient that support
primary nursing diagnosis
Pneumonia: left lower lobe consolidation, atelectasis and pleural effusion
Pulse oximetry of 98% with NC at 14 Lpm
RR rate of 30
Sinus tachycardic at a rate of 160
ABG showing metabolic acidosis
Morbid obesity
Continuation of admitting complaints (SOB, labored breathing)
however, levels have improved
since initial ABG analysis.
2.) The client will be able to move
pulmonary secretions after education
in coughing and deep breathing:
Goal met, the patient was able to
produce a sputum specimen for
culture and sensitivity after using
this expectoration technique.
3.) While on my shift, the client’s
oxygen saturation will maintain
status above 92%: Goal met,
monitoring of oxygen saturation did
not dip below 95% throughout my
shift.
4.) While on my shift, the client’s lung
sounds will improve: Goal not met,
lung sounds remained clear, equal
and diminished.
Identify nursing interventions that you implemented with this patient.
Evaluate patient progress towards achieving outcome criteria as a result of nursing interventions.
1.) Distracted patient from nervous thinking by having him tell me about his family; this allowed his respiratory and heart
rates to decrease for that time period, further allowing for improved breathing pattern and oxygenation.
2.) Raised head of bed to allow for improved lung expansion; this allowed for less labored breathing and for adequate
oxygenation.
3.) Educated on coughing and deep breathing techniques to help remove fluid from lungs; this allowed for the production of
a sputum sample and increased numbers of available alveoli to increase amount of gas exchange.
4.) Assisting in bathing activities with nasal cannula and oxygen, allowing for bodily movement to help remove fluid from
lungs.
What I Would Do Differently
I would have asked more questions about the
bipap settings and the reasoning behind
alternating the bipap with nasal cannula.
I would have provided the client with
information and/or support therapy for his fear
of crowds.
Emphasized the importance of hand washing and hygiene to prevent further infection and spreading the current infection.
References
Carpenito-Moyet, L.J. (2006). Nursing Diagnosis Application to Clinical Practice. Philadelphia, PA: Lippincott, Williams & Wilkins.
Urden, L. (2010) Critical Care Nursing: Diagnosis and Management (6th ed.). St. Louis, MO: Mosby Elsevier.