Fall

GNRS 588
Dr. Alomari

08

AZUSA PACICFIC UNIVERSITY

SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
CARE MAP #: _____2____
Care Map must be completed and submitted within one week of the date of care.

Student: Jelani Carter

Instructor: Professor B. Richards/ M. Medema
Date of Care: XXX, 2015
Date of Submission: XXX, 2015

IERC, 05/2103
[ Ty p e t h e c o m p a n y a d d r e s s ]

GNRS 588
ADMITTING DATA

Interview your patient or his/her family to obtain a complete health history. Do not just copy from the
patients chart unless the patient and family are not available. Total 5.0 points (no point for initial, age,
gender, or medical diagnoses).
Patients Initial
Age
Gender
Weight
Code Status

Medical History
(0.5)

Surgical History
(0.5)
Allergies and
Reactions (0.5)

Psychosocial History
(0.5)

History of Present
Illness
(1.0)
Chronological
account of patients
current illness with
pertinent +s and s
included and correct
medical terminology
used.

XX
87
Male
64.9kg
Full
Cardiovascular
Respiratory
Neurologic
Urinary
Digestive
Endocrine
Musculoskeletal
Hema/Oncology
Infectious
Integumentary
Reproductive
Psychiatric

HTN
Pneumonia
Stroke
UTI
Ulcer
DM

MI
COPD
Parkinsons
ESRD
Diverticulosis
Hyperthyroidism

Dysrhythmias
TB
Guillain-Barre
Renal Failure
Dysphasia
Hypothyroidism

Hyperlipidemia
HF
Acute Respiratory Distre
Glaucoma
Catar

Anemia
Shingles

Cancer:
Hepatitis

Meningitis

STI

BPH
Depression

Anxiety

NA
Vancomycin- gets macular rash

Marital status
Widowed
Education level
Doctoral education in Korea
Social resources
Family present. Patient is father of two KP Fontana physicians.
Spiritual resources
Christian; daughter was speaking to chaplain about being involved with their ch
Occupation
Health field
Employment
Retired
Smoking
Denies
Alcohol
Denies
Recreational Drugs Never
BW is an 87 y/o Korean male with a history of BPH and ulcerative colitis, in apparent remission since
medications with no symptoms. Patient was in usual state of health until he developed cough with SO
Due to continued low grade fevers, patient was given Tamiflu x 3 days then Azithromycin (Zithromax
one week later (2 days prior to admission), patient then started a course of Vantin and Doxycycline the
without significant improvement.

2/17-2/20: Patient was first admitted to KP Ontario Medical Center with URI symptoms - cough, cong
not get flu vaccine- for 2 weeks prior to admission. He was treated with IV Levaquin. Respiratory path
negative for influenza, thus Tamiflu was discontinued. CXR showed diffuse bilateral infiltrates and hi
the thorax showed bilateral parenchymal opacities noted in both upper and lower lobes along with cal
and mediastinal lymph nodes, likely related to old granulomatous disease. Sputum culture was negativ
including a negative respiratory viral PCR. Patient was afebrile and had a normal WBC count on disch
felt better and was sent home with a course of oral antibiotics, Levaquin.

IERC, 05/2103

2/21 (admission): Patient was received A/O x 3 who was previously at home for one night when he w
KP Fontana Medical Center in apparent remission with recurrent pneumonia symptoms- increased pro
SOB, RR 26-30 bpm, O2 sat @ 74% on O2 @ 4L/min NC, but no hemoptysis. No dysphagia or aspira
epistaxis, no hematuria and no significant N/V, diarrhea or rash. Patient was then started on Vancomyc
continued on Levaquin. Fluconazole was started- cocci serologies pending. Patients son noticed macu
abdomen, apparently had it prior with Vancomycin; patient was then switched to Daptomycin. Patient
airborne precautions. Heart monitor showed sinus tachycardia with HR in the 120s. O2 was increased
@ 74-76%, put on simple mask at 10L/min NC, sat @ 86%. He was then placed on NRB with O2 sat
paged and breathing treatment was given. Patient continued to have mild O2 desaturations to 82% and
worsening infiltrates.

2/22: Overnight patient developed worsening of diffuse pulmonary infiltrates with worsening oxygena
work of breathing. Patient was then placed on BiPAP.

OLDCART
Initial Symptom(s) at
the time of admission
(in ED)
(1.0)

2/23: Patient still had a mildly productive cough that had worsened and remained hypoxic despite BiP
response team was called for a change of patient condition of SOB with an O2 saturation of 82%. He
the ED with an O2 saturation of 87%. Patient was then intubated d/t increased secretions and for airwa
then transported to ICU. Right PICC line, right femoral a-lines placed and started on levophed drip fo
to concern for development of ARDS with significant hypoxia, patient was placed on prone positionin
Rotoprone bed.
2/24: CXR significantly improved on prone positioning with improved PaO2/FiO2 ratio.
Patient BW was received awake, alert, oriented x 3. He presented with SOB, RR 26-30 bpm, O2 satur
BP 91/56, sinus tachycardia HR in the 120s with a low grade fever of 99.9 degrees F.

ARDS
Findings that
support/confirm the
medical diagnosis at
admission and
during your care
(1.0)

1.
2.
3.
4.
5.
6.
-

Physical Exam
General Appearance:
Restlessness
Apprehensive
Increasing agitation
Fatigued
Skin:
Clammy, mottled, dusky
Cyanotic
Edematous
Respiratory:
RR: 26-30
Fine crackles
Increased use of accessory muscles
CV:
BP: 91/56
HR: 120s
Low grade fever: 99.9
GU:
Decreased urinary output
GI:
Normoactive bowel sounds, soft, non-tender, non-distended

Diagnostic T
General Appearanc
O2 saturation 82 %
Hypoxic
Skin:
Assessed by touch a
Respiratory:
Auscultation of lung
CXR: bilateral infilt
Respiratory alkalosi
CV:
H/H: 10.7/32.6
Transthoracic echoc
increased workload
- ABGs: (2/23) pH: 7
48.5 HCO3: 25.2
5. GU:
- GFR: >89
- Cr: 0.64
- BUN: 6
6. GI:
- Based on auscultatio
1.
2.
3.
4.
-

IERC, 05/2103

GNRS 588

HEAD-TO-TOE ASSESSMENT
Perform a head-to-toe assessment on your patient.
Total 7.0 points.
General Status (0.5)

VS & Hemodynamics (1.0)

Neurologic & Pupils (0.5)

Head, Face, & Neck (0.5)

ENT (0.5)
Cardiovascular (1.0)

RAAS: -4
Resting peacefully and comfortably in bed
Time

0700

97.6

1000
1300

RR

HR

NIBP

ABP

MAP

24

76

91/54

103/54

65

97.8

24

78

107/54

113/47

71

97.8

24

82

98/53

102/52

63

GCS = 3: eye- 1, motor- 1, verbal- 1

Pupils: equal, round, reactive and accommodating to light; clear and moist; no discharge,
Pupil size: 3/2mm sluggish bilaterally

Head, neck, and face: Edematous; stabilized by roto-prone bed face helmet
Ears: patent, no discharge
Nose: no drainage, both nostrils patent, pink and moist membranes
Throat: dry lips, buccal membranes pink and moist
Rhythm: NSR
Rate: regular; 80-85 bpm
Sounds: no murmurs, gallops, rubs, or bruis; distinguishable S1 and S2 heart sounds
Circulation: capillary refill <3 seconds bilaterally in fingers and toes; bilateral radial, femoral,
normal 2(+), non-bounding; sequential device placed on both lower legs
A-line: right femoral
- Frequent ABGs
- Strict ABP monitoring
Triple lumen PICC: right brachial
- Levophed
- Propofol
- NS
- Abx
Peripheral line: 18 gauge right radial

IERC, 05/2103

Pulmonary (1.0)

Gastrointestinal (0.5)

Genitourinary (0.5)

Skin (wounds) (0.5)

Musculoskeletal (0.5)
Other

- Versed
- Fentanyl
ETT 7.5/ 24mm @ lip to the left with continuous low subglottic suction (placed 2/23)
Breathing: regular pattern, unlabored, equal chest expansion
- Weaning trial (2/25) @ 1040: (off of sedation); Spontaneous, RR- 6, TV- 500mL, Fio
- On this mode for 4 minutes then placed back on A/C 18bpm: TV-500mL, Fio2- 35%, P
- @ 1315: off levophed- Fio2- 30%; A/C- 14bpm; @ 1500- Off all sedation and vasopre
roto-prone bed to regular bed; progressing well
Ventilator
TV
RR
FiO2
PEEP
Mode
A/C 24
550
24
40%
8.0
pH
PaO2
PaCO2
HCO3BE
7.43
137
36.4
24.3
0.0
NGT: clamped
- Secretions: minimal/scant secretions- thin, white, frothy
Cortrak: enteral access system; placed in small bowel (post pyloric) for prone position to prev
- high nitrogen tube feeding formula; 10mL, no flush
- 0mL return
- Medications are given through this tube feeding except for extended release and never
- For patients who need nutritional support for >24hrs
Abdomen: soft, non-distended, non-tender, normo-active bowel sounds; BM 1 day ago
Foley:
- By gravity and staTlock in place; no erythema or edema; Strict I/O monitoring
Urine output:
- >30mL/hr; yellow, clear, no sediment
Generalized edema
- Beginning of shift: face and extremities very edematous
- Mid-shift: no facial edema; some edema in lower extremities
Braden Scale: 9
- Sensory perception: 1; Moisture: 3; Activity: 1; Mobility: 1; Nutrition: 2; Friction/shea
- Mepilex placed over bony prominences to prevent skin breakdown
Not reactive to pain stimuli; passive ROM
Pain scale assessment type: CPOT
- Intubated, non-verbal
PATHOPHYSIOLOGY

On your worn words, describe the: (Total 6.0 points)

Pathophysiology of the admitting diagnosis (4.0 points):

Acute respiratory distress syndrome (ARDS) is a systemic process characterized by non-cardiac pulmonary edema a
the alveolar-capillary membrane as a result of injury to either the pulmonary vasculature or the airways. (Huether & M
519) ARDS is initiated with stimulation of the inflammatory-immune system as a result of a direct or indirect injury
mediators are released from the site of injury, resulting in the activation and accumulation of the neutrophils, macrop
platelets in the pulmonary capillaries. These cellular mediators initiate the release of humoral mediators that cause d
alveolar-capillary membrane (p. 519).

Once released, the mediators cause injury to the pulmonary capillaries, resulting in increased capillary membrane pe
to the leakage of fluid filled with protein, blood cells, fibrin, and activated cellular and humoral mediators into the p
interstitium. As fluid enters the pulmonary interstitium, the lymphatics are overwhelmed and unable to drain all the
IERC, 05/2103

GNRS 588

fluid, resulting in the development of interstitial edema. Fluid is then forced from the interstitial space into the alveo
alveolar edema. Pulmonary interstitial edema also causes compression of the alveoli and small airways. Alveolar ede
swelling of the alveolar epithelial cells and flooding of the alveoli. Protein and fibrin in the edema fluid precipitate t
hyaline membranes over the alveoli, eventually leading to impaired surfactant production. Injury to the alveolar epit
loss of surfactant lead to further alveolar collapse. Hypoxemia occurs as a result of intrapulmonary shunting and V/Q
secondary to compression, collapse, and flooding of the alveoli and small airways. Increased work of breathing occu
increased airway resistance, decreased functional residual capacity (FRC), and decreased lung compliance secondar
compression of the small airways. Hypoxemia and the increased work of breathing lead to patient fatigue and the de
alveolar hypoventilation. Pulmonary hypertension occurs as a result of damage to the pulmonary capillaries, microth
hypoxic vasoconstriction leading to the development of increased alveolar dead space and right ventricular afterload
worsens as a result of alveolar hypoventilation and increased alveolar dead space. Right ventricular afterload increas
right ventricular dysfunction and a decrease in cardiac output (Urden, Stacy & Lough, 2010, p.627). The alveoli bec
irregularly shaped (fibrotic) and the pulmonary capillaries become scarred and obliterated. This leads to further stiff
increasing pulmonary hypertension, and continued hypoxemia (p. 628).

IERC, 05/2103

Correlation between medical/surgical history and admitting diagnosis (2.0 point):

Immunocompromised individuals tend to be susceptible to opportunistic infections and with BWs advanced age, this made him more susce
pneumonia infection. Pneumonia is the acute inflammation of the lung parenchyma that is caused by an infectious agent and can lead to alv
Pneumonia is considered a direct injury because the lung epithelium sustains a direct insult, therefore being a major risk factor for the de
(Baird, Keen & Swearinger, 2005, p. 343).

DIAGNOSTIC TESTS
Include all diagnostic tests and ECG strip.
Remember, a diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease
(i.e. laboratory tests, radiology tests, biopsies, endoscopies, etc.).
Total 6.0 points
Test
CXR

Results
(2/21): Bilateral pulmonary
infiltrates; placement of ETT,
NGT, and Cortrak

Normal Range
Clear

Patient-Specific

Nursing Implic

Etiology
Pneumonia
ARDS

Monitor BP cuff pres

hours during expiratio
way stopcock, calibra

IERC, 05/2103

GNRS 588
Assesses size of
lungs, presence of
fluids, abnormal
gas or fluids in the
pleural sac,
diaphragmatic
margins, the
pulmonary hilum,
as well as integrity
of the rib cage.

(2/24): Significant
improvement; on prone
positioning still, improved
PaO2/Fio2
(2/25):
Continued improvement;
removed from prone
positioning

Presence of fluids
in the lung
parenchyma
initially presents as
pulmonary edema.
The continuous
accumulation
differentiates this
edema formation
to one that is not
cardiac.

CT of thorax
(2/19)

Heart structure WNL

Normal structure

Assesses the threedimensional lung

capacities, fluid
load, and primary
displacement of
the fluid.

Normally a large
gas-filled surface,
the ALI/ARDS
lung when seen on
CT is frequently

mercury manometer.
Change endotracheal
24 hours, inspect the
mucosa, and move en
the other side of the m
Loosen commercial e
holders at least once p
skin care.
Auscultate for presen
bilaterally after insert
changing endotrachea
ties.
Note the centimeter r
the endotracheal tube
possible displacemen
Assist with chest x-ra
needed, to monitor po
Minimize leverage an
artificial airway by su
tubing from overhead
flexible catheter mou
supporting tubes duri
suctioning, and ventil
and reconnection.
Monitor for presence
rhonchi over large air
Monitor for decrease
and increase in inspir
patients receiving me
Institute endotracheal
appropriate.
Institute measures to
spontaneous decannu
artificial airway with
administer sedation a
paralyzing agent as a
arm restraints, as app
Minimize leverage an
artificial airway by su
tubing from overhead
flexible catheter mou
supporting tubes duri
suctioning, and ventil
and reconnection.
Monitor for presence
rhonchi over large air
Institute endotracheal
appropriate.
Institute measures to

IERC, 05/2103

Ultrasound of
abdomen (2/19)

whited out, filled

to with fluid
that has
extravagated
through the
endothelial deficits
(capillary leak).
Pulmonary
congestion

Possible tiny bilateral

effusions. There is diffuse
bilateral reticuloodular
densities along with patchy
airspace disease that appears
slightly worsened bilaterally in
the upper lung zones compared
to prior study. The heart is
normal size
Negative- no pathogens
present

Normal structure

Negative

Bacterial infection

Blood Cultures
(2/21)

Negative- no growth at 3 days

Negative

Infection

Urine Culture
(2/21)

<1000, CFU/mL (no growth)

Negative

Infection

MRSA
Surveillance
(2/21, 2/23)
ABGs

Negative- No MRSA isolated

Negative

Infection

(2/23) (2/24) (2/25)

pH: 7.32* 7.35 7.43
BE: -2.9* -2.2* 0.0
CO2: 48.5* 42.9 36.4
HCO3: 25.2 22.6 24.3
O2:
97.3 98.7 99.9

pH: 7.35-7.45
CO2: 35-45
HCO3:22-26
O2: 80-100

Evaluates the
oxygenation of the
arterial blood as
well as the
presence or
absence of acid
and the effect on
the pH

Sputum Culture
(2/21)

CBC w/diff

(2/23) (2/24) (2/25)

WBC: 13.9* 15.0* 17.8*
Hgb: 9.8* 10.0* 10.7*
Hct: 32.6* 32.4* 30.7*
Plat: 307 357 409*
(2/24) (2/25)

WBC: 4.0--11.0 x
1000/mcL
Hgb: 12-16g/dl
Hct: 36.1-44.3%
Plat: 150-450
billion/L

Indicative of
respiratory
acidosis r/t
hyperventilation.
Respiratory
monitoring d/t
compromised
respiratory effort
Hemodynamic
instability
Leukocytosis is
indicative of
infection

spontaneous decannu
artificial airway with
administer sedation a
paralyzing agent as a
arm restraints, as app
-

Monitor for s/s of inf

Perform proper PPE t
Good hand hygiene

Monitor for s/s of inf

Perform proper PPE t
Good hand hygiene
Monitor for s/s of inf
Perform proper PPE t
Good hand hygiene
Monitor for s/s of inf
Perform proper PPE t
Good hand hygiene
Monitor for s/s of inf
Perform proper PPE t
Good hand hygiene
Maintain patent airwa
Monitor ABGs
Monitor O2 sat
Monitor RR, HR, BP
Maintain patent airwa
Once intubated, sucti
Assess mechanical ve
oxygen therapy
Monitor lab values

Monitor lab values

Monitor for s/s of inf
Monitor I/Os
Monitor O2 sat
Monitor RR, HR, BP
Administer antibiotic

IERC, 05/2103

1
0

GNRS 588
Neut: 95.9* 96.7*

Neut: 42-75%

(2/23) (2/24) (2/25)

Na: 132* 138 143
K: 3.3* 3.4* 4.0
Cl: 106 108 111
CO2: 21
25 24
BUN: 6
7
15
Cr: 0.64 0.83 1.09
GFR: >89 88
64
(2/25)
Mg: 2.7
Phos: 3.2
Mild diastolic dysfunction,
Left ventricular systolic
function is hyperdynamic with
EF >70%, no significant
valvular dysfunction

Ca: 8.6-10mg/dL
Na: 135145mEq/L
K: 3.5-4.5mEq/L
Cl: 99-108 mEq/L
Mg: 1.8-2.2
Phos: 2.44.1mg/dL
Cr: <1.10 mg/dL
BUN: <18 mg/dL
GFR: 90 mL/min
Normal structure

Test is indicative
of monitoring
electrolyte status,

Acid fast bacilli

and fungal
sputum cultures
(2/22)

Negative- smear: no acid fast

bacilli seen

Negative

Infection

Lactate
(2/24,2/25)

2.0mmol/L, 2.2mmol/L

0.4-2.0mmol/L

Lab value being

monitored d/t pts
respiratory state
and current septic
state- acidosis

Chemistry Panel

Doppler
Echocardiogra
m trans-thoracic
(2/21)

Cardiogenic
effects d/t
pulmonary
congestion/edema;
shift of fluids

Hydrate with fluids

Adequate nutrition
Monitor lab values
Monitor for s/s of inf
Monitor I/Os
Monitor O2 sat
Monitor RR, HR, BP
Monitor electrolyte b
Provide supplementa
Provide adequate hyd

Monitor for s/s of inf

Perform proper PPE t
Good hand hygiene
Monitor ABGs
Monitor O2 sat
Monitor RR, HR, BP
Monitor for s/s of inf
Perform proper PPE t
Good hand hygiene
Monitor ABGs
Monitor O2 sat
Monitor RR, HR, BP
Monitor for s/s of inf
Perform proper PPE t
Good hand hygiene
Monitor O2 sat
Monitor RR, HR, BP
and ensure adequate o
administered
Asses urinary output
Monitor lab values

ECG STRIP

HR

Rhythm

P wave

PR

QRS

P:Q ratio

ST
segment

T-wave

IERC, 05/2103

67
Regular
0.12
0.16
0.08
1:1
Interpretation: NSR
(Baird, Keen & Swearinger, 2005, p. 352).
SIX SCHELUED MEDICATIONS AND IV FLUIDS

0.32

0.24

Include all scheduled medications and the PRN if administered. Total 6.0 points.

Medication (Name, Dose, And Route): Proprofol (DIPRIVAN) 1000 mg/ 100 mL IV Premix continuous; Titrate by 5mcg
max of 100mcg/kg/min until RASS -4. Current dose @ 0730- 100mcg/kg/min, titrated down @ 1013 to 50mcg/kg/min, s
Classification
General anesthetic
Mechanism of Action
Short- acting hypnotic. Produces amnesia. Has no analgesic properties
Patient-Specific Indication
Sedation d/t intubation and mechanically ventilated in the ICU
Side Effects and Adverse Effects
The patient may experience the following side effects: dizziness, HA, apnea, cough
abdominal cramping, N/V, flushing, discoloration of urine (green), coldness, numbn
at IV site
The most common side effects being: bradycardia, hypotension, burning, pain, and
Adverse effects include: propofol infusion syndrome
Nursing Implications
1. Dose it titrated to patient response (titrate to desired level of sedation).
2. Frequently causes pain, burning, and stinging at injection site.
3. Propofol has no effect on the pain threshold. Adequate analgesia should always b
propofol is used as an adjunct to surgical procedures.
Patient/family Education
Your father is being given propofol to keep him comfortable while being intubated
the roto-prone bed for his therapy.

Medication (Name, Dose, And Route): Midazolam (VERSED) in NaCl 0.9% 1mg/mL (8mg/hr) IV continuous premix. Stoppe
Classification
Anti-anxiety agents, sedative
Mechanism of Action
Acts at many levels of the CNS to produce generalized CNS depression; short-term
Patient-Specific Indication
Used as a continuous infusion, provides sedations of mechanically ventilated patien
or in a critical care setting
Side Effects and Adverse Effects
Agitation, drowsiness, excess sedation, HA, bronchospasm, coughing, blurred visio
Adverse effects: apnea, laryngospasm, respiratory depression, cardiac arrest
Nursing Implications
1.Administer slowly over at least 2-5min. Titrate does to patient response
2.Assess level of sedation and level of consciousness throughout and for 2-6hr follo
3. Monitor BP, pulse, and respiration continuously during IV administration. Oxyge
equipment should be immediately available
Patient/family Education
This medication is being given to your father to help keep him resting comfortably
bed and while ventilated

Medication (Name, Dose, And Route): Fentanyl in NaCl 0.9% 10mcg/mL (50mcg/hr) IV continuous. Titrate by 25mcg/h
-4
Classification
Opioid analgesic
Mechanism of Action
Binds to opiate receptors in the CNS, altering the response to and perception of pai
depression
Patient-Specific Indication
Supplement in anesthesia; to decrease pain r/t ETT; to enhance patient comfort
Side Effects and Adverse Effects
Side effects the patient may experience include the following: confusion, post-op d
drowsiness, blurred/ double vision, facial itching, N/V, respiratory and circulatory d
bradycardia, hypotension; Adverse effects: apnea and laryngospasm
Nursing Implications
1. Before administering, clarify all ambiguous orders; have second practitioner inde
original order, dose calculations, route of administration, and infusion pump progra
2. Assess type, location, and intensity of pain.
3. Monitor respiratory rate and BP frequently throughout therapy.

IERC, 05/2103

1
2

GNRS 588

Patient/family Education

Your father is being given Fentanyl to help keep him comfortable while being ven
medication will help to decrease any pain that he may be experiencing.

Medication (Name, Dose, And Route): Norepinephrine (LEVOPHED) in D5W 8mg/250mL (32 mcg/mL) IV premix continuou
q3 min to maintain a MAP >65. Current does @ 0730- 4mcg/min; 0800 8mcg/min d/t supine position; by 1200 titrated down to
1315 stopped drip
Classification
Vasopressor
Mechanism of Action
Stimulates alpha-adrenergic receptors located mainly in blood vessels, causing cons
capacitance and resistance vessels; increased BP and CO
Patient-Specific Indication
Produces vasoconstriction and myocardial stimulation, which may be required after
replacement in the treatment of severe hypotension and shock
Side Effects and Adverse Effects
Anxiety, dizziness, HA, insomnia, restlessness, tremor, weakness, dyspnea, arrhyth
chest pain, HTN, decreased urine output, renal failure, hyperglycemia, fever
Nursing Implications
Titrate infusion rate according to patient response, using slowest possible rate to co
Administer via infusion pump to ensure accurate dosage
Patient/family Education
Your father is being given a medication that will sustain his blood pressure at an a
assure that his organs and tissues are receiving adequate oxygenation and nutrition

Medication (Name, Dose, And Route): cefTAZidime (FORTAZ) in D5W IV Premix 2g/500mL (5mL/hr) q8h
Classification
Anti-infective
Mechanism of Action
Binds to the bacterial cell wall membrane causing cell death
Patient-Specific Indication
Lower respiratory tract infection
Side Effects and Adverse Effects
The patient may experience the following side effects: abdominal pain, diarrhea, N/V
superinfection, fever
Some of the most common being: rash, phlebitis at IV site
Adverse effects include: seizures (high doses in patients with renal impairment), alle
including anaphylaxis, pseudomembranous colitis
Nursing Implications
1. Assess for infection (VS, sputum, urine, stool, WBC) at beginning of and through
2. Before initiating therapy, obtain history to determine previous use of and reaction
cephalosporins
3. Obtain specimens for culture and sensitivity before initiating therapy
4. Observe patient for s/s of anaphylaxis (rash, pruritus, laryngeal edema, wheezing)
5. Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools
reported promptly
Patient/family Education
Your father is being given this medication to help fight infection.

Medication (Name, Dose, And Route): methylprednisolone (Solu-MEDROL PF) Inj 60mg q6h
Classification
Corticosteroids, immunosuppressant agent
Mechanism of Action
Suppresses inflammation and the normal immune response
Patient-Specific Indication
Inflammatory response of the immune system to infection
Side Effects and Adverse Effects
Both the adverse and side effects of this drug are more common w
dose/long-term therapy. The most common side effects that the pa
experience include: depression, euphoria, hypertension, anorexia, N
decreased wound healing, ecchymoses, petechiae, adrenal suppres
osteoporosis, cushingoid appearance

IERC, 05/2103

Adverse effects: peptic ulceration, thromboembolism

1. Monitor intake/output ratios and daily weights. Observe patient f
edema, steady weight gain, rales/crackles, or dyspnea
2. Assess for signs of adrenal insufficiency (hypotension, weight lo
N/V, anorexia, lethargy, confusion, restlessness) before and periodi
therapy.
It is very important that this medication be taken as directed. Noti
immediately if your wife experiences any of the following: anorexia
weakness, fatigue, dyspnea, hypotension, hypoglycemia as this can
threatening.

Nursing Implications

Patient/family Education

(Daviss drug guide, 1988).

OTHER MEDICATIONS PATIENT IS RECEIVING

Medication: (Name, Dose, and Route)

Acetaminophen (Tylenol) 650mg tabs q4h PRN via
NGT for temp >100.4 degrees F
Chlorhexidine Gluconate (PERIDEX) Oral Soln 5 mL
q12h (swish and suction)
Docusate Sodium (COLACE) 250mg NG daily
Metoclopramide (REGLAN) 10mg IV q6h
Pantoprazole (PROTONIX) 40mg IV daily (slow push
over 2 min)
Albuterol (PROAIR HFA/ PROVENTIL HFA)
90mcg/actuation HFA MDI 4 puff q4h
Ipratropium 17mcg/actuation MDI 4 puff
(ATROVENT HFA) Inhl q4h given @ 0830, 1120
Heparin Porcine Inj 5,000 units SQ q8h

Linezolid (ZYVOX) 600mg IV premix q12h

Insulin Regular Human Sliding Scale Inj (HumuLIN
R/NovoLIN R) SQ q4h 3units given @ 1000, 1323
Sodium Chloride 0.9% IV premix 75mL/hr
continuous IV
Furosemide (LASIX) 20mg IV (pending order)

Classification and patient-specific

Analgesic and antipyretic used to mana
fever and for pain PRN
Prophylactic. To prevent infection

Laxative. To promote GI motility

Anti-emetic. For nausea from anesthes
Anti-ulcer agent. To prevent ulcer form

Bronchodilator. To control and prevent

airway obstruction
Bronchodilator. Bronchodilation withou
anticholinergic effects; maintenance th
Anticoagulant. To prevent possible form
clots because patient is immobile and
susceptible for this to occur (preventio
thrombus formation)
Anti-infective.
Antidiabetic. Lowers blood glucose to h
healing.
Primary fluid. Mineral and electrolyte
replacements/supplements. Also used
reconstitute other medications
Diuretic. Mobilization of excess fluid (e
pleural effusions)

SYNTHESIS, CRITICAL THINKING, AND PRIRITIZING

Provide a synopsis of your patients hospitalization story. Briefly highlight the acute physiological and psychological alt
needs of your patient. Total 3.0 Points.

Acute physiological alterations: 87 y/o male with history of BPH, non-smoker, history of ulcerative colitis in a
remission here again 2/21 with recurrent pneumonia symptoms. Patient was in usual state of health until he d
with shortness of breath and continued low grade fevers since January 2015. He had been treated without sig
improvement. Patient continued to have mild O2 desaturations to 82% and CXR demonstrated worsening inf
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GNRS 588

Patient remained hypoxic despite BiPAP. 2/23: Patient was then intubated d/t increased secretions and for air
and then transported to ICU and placed on Roto-prone bed. 2/25: Continued overall improvement, now in su
will hold off with further prone positioning. ID discontinued droplet precautions. Started spontaneous awakin
titration of propofol and fentanyl drips. By the end of my shift was taken off levophed, versed and propofol d
and progressing well.

Acute psychological alterations: Mr. BW is currently on a ventilator thus, unable to verbalize his psychologica
from assessment it is appropriate to suggest that Mr. BW could more than possibly feel anxious, nervous and
his current condition. According to the patients daughter and son, prior to Mr. BWs current state of health h
a healthy 87 y/o male who exercised daily, maintained a nutritious diet, and performed all of his activities of d
independently. Mr. BW also attended church regularly and often went fishing with friends. Although, Mr. BW
away 4 years ago, he finds joy in the things that he continues to part take in. Having gone through his recent h
it is safe to assume Mr. BW may have been taken by surprise to be placed in his current situation.

Both physicians of the KP family, Mr. BWs son and daughter showed a great level of respect for the staff, we
pleasant in their demeanor. They were greatly appreciative of the staff and for all of the help and compassion
father has received through this journey. It was rewarding to see how expressive they were in hearing how we
was progressing. They spoke very humbly of the gratitude that Mr. BW would express himself and thankfuln
also have for the care that was being provided to him. They mentioned a few times how strongly their father i
giving credit to his strong willed spirit in wanting to continue on with his normal, daily routine of being outsid
life.

I asked if it would be okay to pray for both them and their fathers condition to have a safe and speedy recove
things may be attained again. They happily accepted and were again, very appreciative of the fact that I want
their family. It was a joyous moment and even more so because I knew that Mr. BW himself, although resting
bed, was praying with us in that moment as well.

Based on your analysis, list the needs of your patient in each of the following areas. Total 7.0 Points (1 point per area).
Basic Care and Comfort
- Keeping a caring and calm environment, low stimulation maintained, l

Health Promotion and Education

blankets used and rest/sleep promoted

Ensuring that patient is shown respect by talking him through what car
provided and informing him of what we are doing as it is being done
Oral care provided q2h
Suction PRN, airway patency maintained
Passive ROM provided
Chlorhexidine bath given; grooming and hygiene
Roto-prone bed settings: 7hrs prone in reverse trendelenberg @ -11 deg
q4min @ 62 degrees then supine for 1hr
Speaking with patients son and daughter about their fathers care and
involving them as much as possible in providing appropriate interventi
Asking patients daughter permission to pray for her fathers condition
Maintaining adequate arterial oxygenation while protecting the functio
highest priority in both traditional and more recent approaches to venti
for ARDS. In addition, the primary goal is to determine and treat the un
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Physiological Needs (high priority)

Physiological Needs (low priority)

Psychological Needs

Pharmacological Considerations

Safety and Infection Control

pathophysiologic condition.
A number of studies have shown that prone positioning the patient with
an improvement in oxygenation. Although a number of theories propos
positioning improves oxygenation, the discovery that with ARDS there
to the dependent areas of the lungs probably provides the best explanat
It was originally thought that ARDS was a diffuse homogenous diseas
areas of the lungs equally. It is now known that the dependent lung are
heavily damaged than the nondependent lung areas.
Turning the patient prone improves perfusion to less damaged parts of
improves V/Q matching and decreases intrapulmonary shunting. Prone
appears to be more effective when initiated during the early phases of A
Positioning to promote adequate perfusion of oxygen through lung tiss
Preventing desaturation by providing adequate oxygenation
Promoting secretion clearance.
Minimize leverage and traction on the artificial airway by suspending v
from overhead support, using flexible catheter mounts and swivels, and
during turning, suctioning, and ventilator disconnection and reconnecti
Institute measures to prevent spontaneous decannulation: secure artific
tape or ties; administer sedation and muscle paralyzing agent as approp
Provide nutritional support. Energy outlay with respiratory failure is hi
of the increased work of breathing. If the patient is unable to consume
with enteral feedings, total parenteral nutrition (TPN) is added. It is im
an occasional evaluation of the patient's caloric and metabolic needs to
the patient is being adequately nourished but not overfed.
Reduce patient anxiety. After insuring adequate ventilation, many patie
anxiety reduction with medication such as fentanyl. Those patients who
adequately oxygenated and ventilated with mechanical ventilation may
reducing agents such as midazolam. A sedation scale and protocol shou
standardize this practice. In addition, the bedside nurse must ascertain
pain and administer analgesics appropriately.
Volume ventilation: A/C; low tidal volume
O2 therapy: lowest level possible to support tissue oxygenation; PEEP
oxygenation while reducing Fio2 to less toxic levels, to open collapsed
flooded alveoli, and increase FRC, thus decrease intrapulmonary shunt
compliance
IVF adjusted, vasopressor support, blood glucose monitoring, anti-mic
PPEs utilized including droplet precautions
Patient ID band checked before administering medications
Safety measures checked
Environment clear of obstacles
Pressure points protected
Careful assessment of lines and tubing placement when roto-prone bed
moving.
Carefully assess Roto-prone settings adjusting per protocol

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Synthesize the patient needs and generate nursing diagnoses. Total 5.0 Points (1 point per diagnosis).
Two High Priority Nursing Diagnoses:
1.
Impaired gas exchange r/t ventilation-perfusion imbalance AEB O2 sat low 80s, tachycardia (HR 120s), change in re
30, abnormal skin color, and restlessness
2.
Excess pulmonary fluid volume r/t capillary-alveolar membrane damage and increase in capillary permeability AEB
congestion on CXR, abnormal breath sounds: crackles, peripheral edema, tachycardia, oliguria, change in respirator
changes, decreased in H/H, mental changes, restlessness, and anxiety
Two Medium Priority Nursing Diagnoses (at least one of them should be spiritual or psychosocial diagnosis):
1.
Anxiety related to threat to biological, psychological, and/or social integrity AEB change in health status and the un
2.
Impaired bed mobility related to environmental constraints AEB Roto-prone bed and sedation
One Low Priority Nursing Diagnosis:
1.
Imbalanced Nutrition: Less Than Body Requirements related to lack of exogenous nutrients or increased metabolic

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Nursing Diagnosis I:
Impaired gas exchange r/t ventilation-perfusion imbalance AEB O2 sat low 80s, tachycardia (HR 120s), change in respiratory pattern
abnormal skin color, and restlessness
Relevant Assessment:
- Abnormal respiratory rate, rhythm, depth; respiratory distress despite BiPAP
- O2 sat: 82%
- RR: 26-30
- HR: 120s
- Temperature: 99.9
- Abnormal skin color
- Crackles heard over upper bilateral lung fields
- Ventilator dependent
Relevant Diagnostic Tests:
- ABGs: pH: 7.32 BE: -2.9 CO2: 48.5 HCO3: 25.2 O2: 80.1%
- CBC: WBCs:17.8; Neutrophils: 96.7%
- Chest x-ray: bilateral infiltrates
Relevant Medications and Therapies:
- Roto-prone bed
- Mechanical ventilation; A/C
- Levophed
- Propofol
- Versed
- Abx: Linezolid (ZYVOX), cefTAZidime (FORTAZ)
- Breathing treatments: Albuterol 2.5mg/0.5mL Inhl Neb Soln, Ipratropium (ATROVENT) 17mcg/ actuation Inhl Soln
Expected Outcomes:
- Patient will achieve appropriate respiratory status: gas exchange AEB. O n initiation of therapy, and the titratio

ventilatory support, the patient has adequate gas exchange as evidenced by the following
values: PaO greater than 60 mm Hg, Pa CO less than 45 mm Hg, pH 7.35 to 7.45. Succe
achieved when the patient can maintain his or her PaO even with FiO decreases.
2

Nursing Interventions with Rationales:

Assess respirations, noting quality, rate, rhythm, depth, breathing effort, and use of accessory muscles. A study demonstrated that
the RR exceeds 30 bpm, along with other physiological measures, a significant cardiovascular or respiratory alteration exists (A
& Ladwig, 2014, p. 375).
- Assess lungs for adventitious breath sounds. Rationale: airway obstruction from fluid accumulation produces crackles and r
Wheezes are caused by bronchospasm (Ackley & Ladwig, 2014, p. 27).
- Assess the characteristics of sputum: color, consistency, amount, and odor. Rationale: abnormalities may be a result of infe
bronchitis, chronic smoking, or other conditions. A sign of infection is discolored sputum (not white or clear); an odor may be pr
Thick, tenacious secretions increase hypoxemia and may be indicative of dehydration (Gulanick & Myers, 2014, p. 408).
- Institute suctioning of airway as needed. Rationale: the frequency of suctioning should be based on presence of adventitious s
and/or increased ventilator pressure. Over-suctioning can cause hypoxia and injury to bronchial and lung tissues (Gulanick & M
2014, p. 409).
- Administer mouth care (mouth swabs, sprays) q2h and PRN; brush teeth at least q12h. Rationale: mouth care helps limit oral ba
growth and promotes patient comfort (Gulanick & Myers, 2014, p. 410).
- Mechanical ventilation. Provide mechanical ventilation with moderate to high levels of PEEP (to prevent tidal collapse) and low
volumes of about 6 ml/kg ideal body weight, to protect the functional lung from overdistention. This lung-protective ventilatory st
has been shown to ensure adequate gas exchange, decrease the levels of intra-alveolar and systemic mediators, and improve out
in patients with ALI and ARDS (Gulanick & Myers, 2014, p. 410).
- Prone patient positioning. Prone positioning of the patient improves the oxygenation of many patients with ARDS. There are v
methods to turn the patient prone mechanically with the Roto-Prone bed (Gulanick & Myers, 2014, p. 410).
- Maintain adequate CO with fluid therapy. Usually, the patient's fluid volume is kept slightly depleted to minimize leakage of e
fluids into the interstitium through damaged capillary membrane. The balance between dehydration and euvolemia is a difficult
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achieve. New measures of total blood volume and arterial stroke volume may assist the provider
in achieving
adequate fluid w
causing volume overload (Gulanick & Myers, 2014, p. 411).
Evaluation
- Goal met AEB patient achieving adequate gas exchange as evidenced by the following ABG values: PaO2 greater than 60 m
PaCO2 less than 45 mm Hg, pH 7.35 to 7.45

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NURSING DIAGNOSIS
Total 25.0 Points

*
*

Nursing Diagnosis II:

Excess pulmonary fluid volume r/t capillary-alveolar membrane damage and increase in capillary permeability AEB pulm
CXR, abnormal lung sounds: crackles, peripheral edema, tachycardia HR 120s, oliguria <30mL/hr, change in respirato
changes, low H/H, mental changes, restlessness, and anxiety
Relevant Assessment:
- Abnormal lung sounds: crackles
- Peripheral edema: face and extremities
- Tachycardia: HR- 120s
- RR: 26-30
- Urine output: <30mL/hr
- BP changes:
- Restlessness and anxiety
Relevant Diagnostic Tests:
- CXR: bilateral pulmonary infiltrates
- H/H: 10.7/32.6
- ABGs: pH: 7.32 BE: -2.9 CO2: 48.5 HCO3: 25.2 O2: 80.1%
- U/S: diffuse bilateral reticuloodular densities along with patchy airspace disease
- UA: negative
- Cr: 0.64
- BUN: 6
Relevant Medications and Therapies:
- Lasix
- Repositioning: roto-prone bed
- Levophed
- Abx: Linezolid (ZYVOX), cefTAZidime (FORTAZ)
Expected Outcomes:
Patient will be normovolemic AEB, balanced intake and output, stable weight, absence or reduction of edema, HR 60-100
pulmonary crackles
Nursing Interventions with Rationales:
- Listen to lung sounds for crackles, monitor respirations for effort. Acute pulmonary edema may be due to increase
alveolar capillary barrier (Ackley & Ladwig, 2014, p. 371)
- Monitor location and extent of edema, use the 1+ to 4+ scale to quantify edema. Note differences in measurement
Causes of peripheral edema in patients with heart failure are r/t medications, compensatory changes that influence
and fluid retention (Ackley & Ladwig, 2014, p. 371)
- Monitor input/output closely. Accurately measuring intake and output is important for the client with fluid volume o
of all fluids should be measure (Ackley & Ladwig, 2014, p. 371).
- Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea.
- Monitor serum and urine osmolality, serum Na, BUN/Creatinine ratio, and hematocrit for abnormalities. In a patien
and increase in urine volume and dilution will usually be observed. BUN and creatinine are monitored currently, bu
and an overall assessment of patient fluid status is critical prior to fluid administration (Ackley & Ladwig, 2014, p. 3
- Monitor the clients behavior for restlessness, anxiety, or confusion; use safety precautions if symptoms are presen
volume comprises CO, the client may experience cerebral tissue hypoxia and demonstrate restlessness and anxiety. W
volume results in hyponatremia, there is a shift of water into the cells, resulting in symptoms such as nausea, ma
cramping to confusion, seizure, and coma. (Ackley & Ladwig, 2014, p. 371).

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Maintain the rate of all IV infusions, carefully utilizing an IV pump. This is done to prevent inadvertent exacerb
volume (Ackley & Ladwig, 2014, p. 372).
- Prone patient positioning. Prone positioning of the patient improves the oxygenation of many patients with ARD
methods to turn the patient prone mechanically with the Roto-Prone bed (Ackley & Ladwig, 2014, p. 372).
Evaluation
Patient goal partially met AEB patient urine output >30mL/hr, stable weight, absence or reduction of edema, HR 60-100 b
absence of pulmonary crackles.

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REFERENCES
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care.

Baird, M. S., Keen, J. H., & Swearingen, P. L. (2005). Manual of critical care nursing: Nursing
interventions and collaborative management. St. Louis, MO: Elsevier Mosby.
Davis's drug guide for nurses. (1988). Philadelphia: F.A. Davis.
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. St. Louis:
Elsevier/Mosby.
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, MO: Elsevier.

Urden, L. D., Stacy, K. M., & Lough, M. E. (2010). Critical care nursing: Diagnosis and
management.

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