Fortis College
Nursing Care Plan
Patient Demographics
Student: _Brenda Davis_____ Clinical Site: __JVH_______ Date: ___08/06/2014_______________
Client Initials: __E.D.__ Age: __65_______ Weight: _75.7 kg Height: ___69________in.
Primary Language:_English____ Religion: _LDS, active in church__ Culture: __Retired lives with daughter and son-on law, they are at the bedside off and on throughout the day____________________
Admitting Diagnosis: ___Pneumoia_________________________________________________________
Secondary Diagnosis: __Hypoxia___________________________________________________________
Allergies & Reactions: __No Allergies_______ Code Status: DNR_____ Physician:__Chandler________

History of Present Illness (Please include a detailed description of the present illness including past medical and surgical history-paint a picture) What brought your client to this facility?

Mrs. D is 65 year old Caucasian female presents in the ED for shortness of breath and difficulty taking deep breaths. Past medical hx includes depression, anxiety and MS. Past surgical history includes hernia repair. Patient reports she has 4 children and 3 of them live in other states. Her daughter that lives locally is her primary caregiver. Patient does not smoke “quit 20 years ago and smoked 1 pack a day for 15 years” and she does not drink. She was admitted to the facility 8/4/14 for pneumonia and hypoxia. Patient is unable to take care for self she requires assistance with ADL’s. Patient reports that when she takes a deep breath in, has pain on the right side. Has unproductive cough, decreased lung sounds in all lung fields. Unable to get adequate sleep because of Shortness of breath. Ego integrity vs despair stage of development. Alert and oriented x’s 3. Patient is forgetful when family is in the room. Mood appropriate.

Orders/Treatments (include cares/procedures ordered for the patient except for med and labs)

Monitor Vital signs every 4 hours, O2 @ 6 lpm NC to keep O2 above 90%. Can switch to re-breather mask if oxygen saturation requirement is not met. Antibiotics. Telemetry.

Pathophysiology (Include Pathophysiology of the presenting diagnosis at the cellular level – not procedure or surgery –Include treatments as well as relating your “text book” picture to your patient).

Pneumonia- Microorganisms enter the alveolar spaces by droplet inhalation, inflammation occurs, and alveolar fluid increases. As a result, gas exchange is impaired and ventilation decreases as secretions thicke Pneumonia has caused an infection of the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, causing fluid into the alveoli causing disruption in gas exchange, which makes breathing painful and limits oxygen intake (Lewis, 2011).
Hypoxia reduction in PO2 below the normal range, regardless of whether gas exchange is impaired in the lung, it is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. When an individual has pneumonia the patient has limited gas exchange which results in hypoxia (Lewis, 2011).

Physical Assessment

Body Systems

Actual or Potential Nursing Diagnosis

General Appearance: 65 year old woman, appears older than stated age

 

Vital Signs:
B/P 128/78 L arm sitting
Temp: 99.5 F Tympanic Pulse: 72 bpm Respiration: 18 bpm
Oximetry: 94 % on 6 lpm n/c
Pain Assessment: reports no pain currently. Often has pain 4/10 when coughing. Dull pain that is relieved by sitting up in bed.

Ineffective breathing pattern r/t pneumonia
Activity intolerance r/t imbalance between oxygen supply and demand.

HEENT:
Inspect Head: No Lesions present
Visual Acuity Wears corrective lenses
Hearing acuity: No evidence of hearing aids, patient responds to whisper test.
Nose: Mucosa is pink and moist. Septum is midline. Nares are patent with no drainage
Mouth/Throat: Trachea is midline. Patient wears dentures upper and lower. Oral mucosa is pink, moist with no lesions.Lymph nodes non palpable.

 

Neurological:
Orientation: Alert and oriented X’s 3 when in the room alone. When family is in the room the patient is forgetful and often oriented only to self. No acute signs of distress, patient canfollow verbal commands
PERRLA
Gross Motor sensation is present in all extremities
Swallow: Gag reflex not assessed, but patient swallows without difficulty
Cranial Nerves: See previous body systems

 

Respiratory:
Breathing inspection:Respirations 18/min, shallow and even
Breath Sounds:Decreased coarse breath sounds auscultated over all lobes
Chest expansion symmetric, mildrefractions. No pain or tenderness on palpation. Pain on inspiration
Cough:non-productive cough present
Oxygen therapy:94% on 6L/min
Skin Color:pink, intact, no edema

Impaired gas exchange

Cardiovascular:
Edema: No edema present
Pulses- Apical 72 bpm regular rhythm, all other pulses 2+ strong bilateral
Auscultation: S1 and S2 auscultated. Carotid pulse equal bilateral, no bruits auscultated. Regular rate and rhythm without murmurs.
Capillary Refill:
 

Gastrointestinal:
Inspect abdomen: Soft, non-tender, non-distended upon palpitation. Skin of abdomen free of lesions and rashes.
Bowel sounds x4: Active Bowel sounds in all 4 quadrants.
Last BM: Last BM was today, normal consistency, patient is in a brief but will ask to go to the bathroom.
Diet/Appetite : Mechanical soft diet, needs assistance to eat. Ate 50% of meals today.

Imbalanced nutrition: Less than body requirements related to inability to eat on own

Genitourinary:
Catheters: 18 French catheter
Quality of Urine: Dark amber urine
Continence: incontinent.
Voiding Frequency Urgency: without urgency
Painful: denies painful urination

 

Musculoskeletal:
ROM, strength upper & lower extremities: Limited ROM in lower extremities. Full ROM in upper extremities. Wheelchair bound
Activity Level: Up to chair with assistance.
Gait: uneven gait. Will stand and shuffles to try walk.

 

Integumentary:
Skin: pink, warm to touch, turgor rapid recoil,no edema, cyanosis, or clubbing
Drains, drainage, dressing: 18 g LEJ ½ NS @ 50cc. Dressing clean, dry intact without redness or swelling. No other dressings or drains noted
Pressure Points: Braden scale 14 high risks. Morse fall scale 28 high risk

 

Emotional/Psychological: Anxious, angry etc: Patient is very pleasant when she is alone. Appears anxious when family is in the room with her.
Appropriate: Appropriate to situation
Sleep Patterns: Altered sleep patterns, patient is restless. Nurse reports patient only slept 3 hours last night. Patient states “I am very tired.”
Erickson’s developmental stage: Ego vs. Despair

Impaired comfort r/t hospitalization
Anxiety related to change in health status

LABS

Lab Test

Patient Value
Admit Current

Normal Range

Rationale for Abnormal (apply this to YOUR patient)

CBC

 
 

RBC

 
 

4.1-6.0

 

Hgb

 

11.0 (l)

12-18g/dL

Low related to pneumonia and decreased oxygenation (Pagana, 2010)

Hct

 

33.0 (l)

38-48%

Low related to pneumonia and decreased oxygenation (Pagana, 2010)

WBC

 

8.0

5.0-10.0

 

Neutrophils

 

56.4

55-70%

 

Lymphocytes

 

28.0

20-35%

 

Monocytes

 

4.2

3-8%

 

Eosinophils

 

1.5

1-3%

 

Basophils

 

0.7

0.5-1%

 

Bands

 
 

0-11%

 

Platelets

 

210

150-400

 

CMP

 
 

Na+

 

143

135-146mEq/L

 

K+

 

2.6 (l)

3.5-5.1mEq/L

Low due to dehydration or other electrolyte imbalance (Pagana, 2010)

Cl-

 

108

95-105mEq/L

 

CO2

 

30

24-32mEq/L

 

Glucose

 

103

60-110mg/dL

 

BUN

 

13

6-20mg/dL

 

Creatinine

 

.7

0.6-1.4mg/dL

 

Calcium

 

9.2

8.5-10.5mg/dL

 

Total Protein

 

6.1

6.0-8.0g/dL

 

Albumin

 

3.9

3.5-5.0g/dL

 

Alk Phos

 

90

38-126 U/L

 

ALT

 

11

10-35 U/L

 

AST

 

15

8-38 U/L

 

GGT

 
 

4-23 U/L

 

Phosphorus

 
 

3.0-4.5 mg/dL

 

Magnesium

 
 

1.3-2.5mEq/L

 

CRP

 
 

 

ESR

 
 

0-20mm/hour

 

PT
INR

 
 

9.5-12 sec
1.0 (normal)
2.0-3.0 (therapeutic)

 

PTT

 
 

20-45 sec

 

LIVER

 
 

Total Bilirubin

 
 

0.1-1.0 mg/dL

 

Direct Bilirubin

 
 

0.0-0.4 mg/dL

 

Indirect Bilirubin

 
 

0.4-1.0 bg/dL

 

Ammonia

 
 

15-45mcg/dL

 

CARDIAC

 
 

Total Cholesterol

 
 

140-200 mg/dL

 

LDL

 
 

60-160 mg/dL

 

HDL

 
 

29-77 mg/dL

 

Triglycerides

 
 

40-190 mg/dL

 

CK

 
 

25-200 U/L

 

CK-MB

 
 

0-7 U/L

 

Troponin

 
 

 

BNP

 
 

 

GASTROINTESTINAL

 
 

Amylase

 
 

56-190 U/L

 

Lipase

 
 

0-110 U/L

 

H. pylori

 
 

Negative

 

Stool Occult Blood

 
 

Negative

 

ENDOCRINE

 
 

TSH

 
 

0.5-5.5uU/mL

 

T3

 
 

800-200ng/dL

 

T4

 
 

4-12ng/dL

 

Hgb A1c

 
 

4-7%

 

RESPIRATORY

 
 

ABG

 
 
 
 

pH

 
 

7.35-7.45

 

pO2

 
 

80-100mmHg

 

pCO2

 
 

35-45mmHg

 

HCO3

 
 

22-26mEq/L

 

URINALYSIS

 
 

pH

 
 

4.6-8.0

 

Specific Gravity

 
 

1.01-1.025

 

Protein

 
 

Negative

 

Glucose

 
 

Negative

 

Ketones

 
 

Negative

 

Bilirubin

 
 

Negative

 

Nitrites

 
 

Negative

 

Leukocyte esterase

 
 

Negative

 

WBC

 
 

0-5/hpf

 

RBC

 
 

0.4/hpf

 

Casts

 
 

None to occasional

 

CULTURES

 
 

Urine

 
 

No Growth

 

Stool

 
 

No Growth

 

Wound

 
 

No Growth

 

Blood

 
 

No Growth

 

Sputum

 
 

No Growth

 

 
 
 
 
 

DIAGNOSTIC TESTS

DIAGNOSTIC TEST

DATE

PATIENT’S TEST RESULTS AND RATIONALE

EKG

 
 

X-RAY

8/4/14

CXR single view. Low lung volumes are present. No pneumothorax. Bilateral lower lobe pneumonia

ULTRASOUND

 
 

CAT SCAN MI

 
 

ULTRASOUND

 
 

CARDIAC CATHETERIZATION

 
 

ECHO

 
 

VENOUS DOPPLER

 
 

BRONCHOSCOPY

 
 

BIOPSIES

 
 

SCOPES (EX. Colonoscopy)

 
 

LUMBAR PUNCTURE

 
 

EEG

 
 

Other:

 
 

MEDICATIONS

Drug /Trade & generic /Class

Dosage/route/schedule

Reason for Use

Nursing Consideration

Levaquin/Levofloxacin
Anti-infective broad spectrum antibiotic that inhibits DNA into bacteria

750 mg PO daily

Treatment of pneumonia

Obtain C & S prior to therapy, Assess for previous allergic reaction, monitor I & O, assess for diarrhea (Skidmore-Roth, 2013).

Enoxaprin/Lovenox
Low molecular heparin with antithrombotic properties

40 mg SC daily

Prevention of clots

Assess coagulation studies, monitor bleeding (Skidmore Roth, 2013).

Tylenol

625 mg Q4hrs prn

Pain or fever

Monitor for S&S of: hepatotoxicity , Do not take other medications containing acetaminophen without medical advice (Skidmore Roth, 2013)

Prozac/fluoxetine hydrochloride
elective serotonin reuptake inhibitor

40 mg PO daily

Depression

Use with caution in the older adult patient, lab tests: periodic serum electrolytes; monitor closely plasma glucose in diabetes, serum sodium level, weigh weekly to monitor weight loss (Skidmore Roth, 2013).

Xanax/alprazolam benzodiazepine

1 mg PO prn

anxiety

Assess anxiety, Monitor BP, Monitor hepatic function and CBC with long time use. Assess mental status (Skidmore Roth, 2013).

Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)

Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)

Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)

Rationale
Give one reason for each nursing intervention that is performed.

Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.

# 1.
Impaired gas exchange r/t inadequate airway and alveolar clearance secondary to pneumonia, aeb decreased coarse breath sounds and shortness of breath (Ackley, 2012).

Patient will demonstrate the use of incentive spirometer 10 times every hour by 1 pm.
Patient will remain free of respiratory distress and maintain clear lung fields throughout the shift.

Assess LOC and distress.
Monitor respiratory rate and depth and ease of breathing. Watch for use of accessory muscles and nasal flaring.
Teach how to use incentive spriometer and deep breathing exercises.

May indicate worsening hypoxia.
Indicates if there is a change in respiratory status.
Helps open up the airway for ventilation and keeps alveoli open.

Patient is using incentive spirometer, patient is partially meeting goals.

Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)

Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)

Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)

Rationale
Give one reason for each nursing intervention that is performed.

Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.

# 2.
Ineffective breathing pattern r/t pneumonia aeb SOB, shallow breathing, and decreased oxygen saturation levels (Ackley, 2012).

Patient will be able to verbalize understanding of proper deep breathing techniques by 1 pm.
Patient will establish normal breathing patterns by discharge.

Assess respiration rate, rhythm, and depth.
Monitor deep inspirations to increase oxygenation.
Teach appropriate deep breathing, and coughing techniques.

Early signs of respirator difficulties.
Increase oxygenation.
Clears secretions.

Patient is working on deep breathing. Patient demonstrates understanding of deep breathing and coughing to clear lungs. Goals are partially being met at this time.

Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data
(AEB or Risk Factors)

Goals (SMART)
1-Short term goal (STG)
1-Long term goal (LTG)
(Specific, Measurable, Attainable, Realistic, Time frame)

Interventions
3 for each diagnosis:
assess, monitor, teach/educate, etc.
(Must also include frequency)

Rationale
Give one reason for each nursing intervention that is performed.

Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.

 

# 3.
Impaired comfort r/t hospitalization aeb restlessness, disturbed sleeping patterns, and confusion (Ackley, 2012).

Identify strategies to improve or maintain comfort by 10 am.
Maintain an acceptable level of comfort throughout shift.

Assess patients current level of comfort.
Enhance feelings between the patient and those providing care.
Offer suggestions for improving comfort by breathing to relax and utilize empathy in response to patient’s negative emotions.

Identifies baseline for patient.
To attain the highest comfort, patient must trust those providing care.
Helps patient to identify strategies that work for her. Empathy also promotes trust.

Patient is developing trust with the hospital staff. However, when family is present patient does not speak up. Goals are not being met currently.

References
Ackley, B. J. &Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. (10th ed.). St. Louis, MO: Mosby Elsevier.
Jordan Valley Hospital, Electronic medical records, West Jordan UT.
Lewis, S.,Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby-Elsevier.
Pagana, KathleenDeska,Pagana, Timothy J. (2010). Mosby’s Manual of Diagnostic and Laboratory Tests (4thed). St. Louis, MO: Mosby Elsevier.
Skidmore-Roth, Linda, (2012) Mosby’s Drug Guide for Nurses, with 2012 Update: 9th Edition