care plan help

Published Apr 9, 2009

5 Posts

i'm looking for a little help with my care plan. here's a little bit about my patient.

patient is a resident of an extended care facility (ecf) where she was in her usual state of health previous to admission. patient had been alert and oriented over the previous weekend. oxygen saturation suddenly dropped to 58%, patient presented to the emergency department with a chief complaint of mental status changes, difficulty in breathing, and dropping oxygen saturations. patient is confused to person, unable to respond to questions, or verbalize problems. patient vital signs are: blood pressure (bp)- 90/59, temperature- 98.1 per oral (po), pulse- 103 and regular, respiration 18, and oxygen saturation of 86% on 4 liters (l) nasal cannula (nc). upon assessment the patient is alert and orientated x4, no motor or sensory deficit, denies any distress. sinus tachycardia, s1 and s2 present. pulses 2 + bilateral radial and 2+ bilateral pedal. bilateral foot drop noted. upon auscultation anterior and posterior breath sounds were diminished throughout with bilateral diffused crackles throughout. abdomen obese, soft, tender over right upper quadrant. a colostomy noted in the right lower quadrant. bowel sounds active x4 quadrants. skin color ethnically normal, warm, no tenting, no rash. the medical treatment for respiratory failure and uti include broad spectrum antibiotics, vasopressors, and critical care consultation. patient was placed on acute bed rest and transferred to intensive care unit on 3/18/09 for further treatment. on 3-19-09 patient was experiencing dyspnea, diaphoresis, tachycardia, o2 sat of 85%. patient was placed on the vision bipap to prevent intubation. bipap settings of 15/5 titrate o2 to keep spo2 greater than 92%. the bipap was tolerated for a few hours then patient became tachypneic, rate 40-46 and tachycardic, heart rate greater than 140 with frequent premature ventricular contractions, the decision was made to intubate the patient. orally intubated with # 8 french et tube and placed on the vent with settings of tidal volume- 500, rate-30, fio2-65%, peep of 12. a #18 orogastric tube (ogt) was inserted and connected to low suction to prevent aspiration and placement for both were confirmed by x-ray. braden score of 10, patient is turned every 2 hours, a skin bundle is used to protect his heals, and skin barrier cream is used for the patient bony prominences. patient's height is 5'7", weight is 244 lbs, and the body mass index (bmi) is 38.2 which is considered morbidly obese. the patient's glasgow coma scale (gcs) is 3 due to sedation and paralytic agents. patient's 24 hour i & o: 2571ml of fluids in and 1400ml of fluid out. patient's abgs were ph-7.39, pco2-38, po2-57.1, o2-86.3, hco3- 22.6, patient did not tolerate lowering peep.

patient's computed tomography (ct) image showed air space disease with in both lungs, left side greater than the right, and most prominent in the bases. this correlates clinically for potential of pulmonary edema rather than bilateral pneumonia. ct also shoes enlarged heart, atrophic pancreas, and moderate amount of free fluid in the pelvis. relevant laboratory tests on include chloride 121 (101-111); bun 33 (8-26); creatinine .45 (.44-1.00); phosphate 201 (32-91); calcium 7.7 (8.9-10.3); cholesterol 267 (142-200); cpk 13 (38-234); protein 5.4 (6.5-8.1); albumin 2.8 (3.5-5.0); hemoglobin 8.5 (11.0-16.2); hematocrit 24.5 (36-46); wbc 16.9 (4.5-11.0); rbc 2.80 (3.30-5.30), platelet 121 (140-440).

i have impaired gas exchange related to ventilation perfusion imbalance as evidence by respiratory rate of 38, oxygen from 4 l nc to vent support, lasix, breath sounds are diminished throughout with bilateral diffused crackles throughout. i still need three more one being psychosocial. thanks for all you help!