Allergies: methotrexate, naproxen, oats, plaquenil sulfate The MEDICAL DIAGNOSIS that brought the client to the hospital is: Interstitial lung disease PATHOPHYSIOLOGY of diagnosed disease: (From text) The interstitium is the area between the capillaries and the alveolar space. In the normal state, this space allows close apposition of gas and capillaries with minimal connective tissue matrix, fibroblasts, and inflammatory cells such as macrophages. The interstitium supports the delicate relation between the alveoli and capillaries, allowing efficient gas exchange. When responding to any injury, whether from a specific exposure, an autoimmune-mediated inflammation from a systemic connective tissue disease (rheumatoid arthritis), or unknown injury, the lung must respond to the damage and repair itself. If the exposure persists or if the repair process is imperfect, the lung may be permanently damaged, with increased interstitial tissue replacing the normal capillaries, alveoli, and healthy interstitium (Chapman, 2010). SYMPTOMS typically seen with this diagnosis include (as identified in your text): Dyspnea Nonproductive cough Sputum production Hemoptysis Wheezing (Chapman, 2010) CLIENTS SYMPTOMS of the diagnosed disease include: Temperature of 38.6 HR in 150s-160s Respiratory Rate of 26 Atrial fibrillation Shortness of breath No sputum production Peripheral edema NUTRITIONAL ASSESSMENT: Height (actual or estimated): 157.42 cm Weight (actual or estimated): 84.5 kg
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5): 46 is the ideal body weight for patient
Does this client have characteristics of a well-nourished person? Yes __X___ No _____ Explain your answer. Patients skin is not dry, hair is shiny and not falling out. Her nails are non-brittle and she is not skin and bone. Her lips are not cracked and smooth.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the clients developmental stage? Ego integrity vs. despair
Has he/she met the necessary accomplishments? Yes __X__ No _____ Explain. Patient and husband are in a good standing relationship. Husband comes in each morning to do devotionals with the patient even though she is on a ventilator. Husband also talks amount their sons and daughters and how he is proud of them. They are also involved with the church and the church has been praying for the patient consistently. (Eriksons Psychosocial Stages Summary Chart, n.d.).
How is this illness affecting the clients ability to meet these necessary accomplishments? Patient was actively involved with the church and her family, however now she is unconscious and mostly asleep. She is not arousable and grimaces to pain. Her inability to communicate and breath on her own may can be a problem with her development stage. However, her husband has been talking to her which is very important.
Stress Management: Identify coping mechanisms used by this client during stress.
Explained to patient the care given even though she was unconscious. Held patients hand during wound care. Spoke in a calming voice when in the room. NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS Indicate below the 2 priority nursing diagnoses that are most relevant for your client. #1 NURSING DIAGNOSIS (problem r/t) Impaired gas exchange r/t to ventilation-perfusion mismatching. DEFINING CHARACTERISTICS (S/S) that support this diagnosis: Somnolence Inability to move secretions Hypercapnia Hypoxia
OBJECTIVE/CLIENT OUTCOME for this diagnosis: Patient improves gas exchange as evidenced by normal ABGs and alert responsive mentation and further reduction in mental status by 09/30/14.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Monitor effects of position changes on oxygenation (SaO2, ABGs, SvO2, and end tidal CO2).
2. Monitor arterial blood gases (ABGs) and note changes.
3. Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis.
4. Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds.
(Galanes, 2012)
#2 NURSING DIAGNOSIS (problem r/t) Ineffective airway clearance r/t increased airway resistance associated with edema of the bronchial mucosa and pressure on the airways resulting from engorgement of the pulmonary vessels. DEFINING CHARACTERISTICS (S/S) that support this diagnosis: Somnolence Diminished breath sounds Abnormal blood gases Significant decrease in oximetry results
OBJECTIVE/CLIENT OUTCOME for this diagnosis: The client will experience adequate respiratory function as evidenced by usual or improved breath sounds, usual mental status, and blood gases within normal range by 09/30/14.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Administer the following medications if ordered: diuretics to decrease fluid accumulation in the lungs or morphine sulfate to decrease pulmonary vascular congestion in acute pulmonary edema. 2. Perform actions to promote removal of pulmonary secretions like humidifing inspired air as ordered to keep secretions thin. 3. Help client to change positions, turn, and perform ROM exercises. (Nurses Diagnosis: Impaired, 2012)
COMPLICATIONS: If this clients condition were to worsen, what would be the most likely reason and why? Worsening heart and lung failure resulting in unresolved hypoxia.
How would you know this is happening? Patient is pale Decreased p02 Labored breathing Decreased BP
What will you do if this happens? Call the health care provider Raise head of bed Prepare for intubation Administer medication to help cardiac fixation
Evaluation: Was the patient able to achieve the objectives identified on the first clinical day? Yes
Did you choose the appropriate nursing diagnosis on the first clinical day? Yes
Were the interventions appropriate? Yes
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/DIET (Include dose, route, frequency) REASON PRESCRIBED (Drug Classification, What is it treating?) NURSING IMPLICATIONS FROM TEXT (Checking for adverse reactions, preparation & administration concerns) CLIENT DATA FROM YOUR ASSESSMENT (What data is important to know before & after giving) diltiazem 30mg=1 tab once daily Calcium channel blocker Decreases heart rate Can cause severe hypotension Check blood pressure and apical pulse before giving Adverse reactions include dizziness and swelling Can cause dermatitis. Patient has cellulitis on right leg. Used because unresponsive to metropolol. Albuterol 2 puffs Once daily Adreceptor agonist Helps with inflammation and breathing Prevents asthma attacks Can decrease immune system-avoid people who are sick If allergic to milk proteins medication should be avoided. Higher doses should be watched with arrhythmias. Patient is 81 and can decrease immune system Watch out for infection and use all standard precautions. Patient experiencing Atrial fibrillation. Ascorbic acid Vitamin C Important for connective tissue Drink plenty of liquids Patient has interstitial lung disease ERTApenem Antibiotic Fights cellulitis Powder is mixed with liquid. Given slowly at least for 30 minutes. Antibiotic given for cellulitis on right leg. Furosemide Loop diuretic Help with fluid overload and hypervolemia Can cause hyperkalemia Can cause tachycardia. Patient experiencing Atrial fibrillation. Heparin Anticoagulant Blood thinner Increased bleeding over age 60 Thrombocytopenia can occur. Skin necrosis may occur in the wound (cellulitis) on right leg. Prednisone Corticosteroid Synthetic anti- inflammatory May mask signs of infection Patient is 81 and can decrease immune system Watch out for infection and use all standard precautions. Used for inflammation in
lungs. Metropolol 25 mg BID Beta 1 selective adrenergic receptor antagonist Can cause severe hypotension. Dyspnea is a side effect. Decreases BP in patient because of Atrial fibrillation. Patient was given Cardizem because patient was unresponsive to metropolol. (National Library of Medicine - PubMed Health, n.d.)
Analysis of Diagnostic Tests
DIRECTIONS:
1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and provide the patient values for each test. Explain why they are pertinent for this patient.
2. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test Patient Values Analysis of Values MRI of spine and head
(-) no acute infarction Atrial fibrillation and irregular rate and rhythm so MRI was given. Lumbar puncture was done Cardiac monitor
Heart rate in the 150s Atrial fibrillation. Metrolol 25mg BID for rate controlled. Will restart heparin when Hb stabilizes. Troponin T 0.054 H Increased troponins likely due to respiratory failure. WBC
9.6 L Antibiotics still need to be given. Hgb
91 L The low level is primarily due to her acute anemia. Hb
6.7 L The low level is primarily due to her acute anemia. 2 units of PRBCs was given.
DR chest-single view
No new acute cardiopulmonary process identified Decreased lung sounds in bases. Intubated and bronched 40% so a DR chest-single view was taken. PEEP is at 5
References
Eriksons Psychosocial Stages Summary Chart. (n.d.). Retrieved March 31, 2014, from http://psychology.about.com/library/bl_psychosocial_summary.htm Chapman, J. (2010).Interstitial lung disease. The Cleveland Clinic Foundation. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/inter stitial-lung-disease/ Nurses Diagnosis: Impaired respiratory function. (2012). Saunders. Retrieved from http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=130 Galanes, S. (2012). Gas exchange, impaired: Ventilation or perfusion imbalance. Mosbys Guide to Nursing Practice (3 rd ed). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick23.ht ml National Library of Medicine - PubMed Health. (n.d.). Retrieved March 31, 2014, fromhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0010993/?report=details#warnin g