OK, I am very new to this- but I am going to give it my best shot.
I had a 59 year old female patient-
DX- bilateral lower ext. cellulitis(from fungal infection), COPD, DM, Morbid Obesity (unsure of weight- couldn't be weighed at hospital, and had not been weighed accurately in a few years)
Receiving 160 units of 70/30 insulin in the am, and 90 units at hs, as well as coverage with sliding scale, also receiving albuterol and atrovent updrafts, solumedrol 80 IVP, lasix 80 po, ancef 1gram IVPB, advair, zocor, and synthroid. Coumadin was on hold for elevated INR. She also received several ointments to areas of lower ext. that had been Incised by the doc, and debrided (Fungal growths, and really interesting)
Anyway- she had SOB with casual conversation that was worsened with any activity. Lung sounds clear, but diminished in lower lobes. O2 going at 5L per n/c, and respirations @ 26 with HOB up, O2 sat 93-95%. Edema, 2 and 3 plus to lower ext. (PITTING) Required coverage with regular insulin for FSBS of 319 at 1130 accucheck.
Urinary output adequate- BUN and Creatinine slightly elevated, WBC slightly elevated, but going down, Potassium WNL, no ABG's on chart.
She attempted to turn and position herself, and help with her care, she was pleasant, and anxious to learn.
Now- I want to go with this-Impaired Gas Exchange related to alveolar-capillary membrane changes-
can you tell me if I am headed the right way?
Any help would be greatly appreciated, and thanks!!
It is difficult for me to come up with goals- don't know why, but especially in this case- as I have no ABG's
I guess I could go with -short term goal- Will exhibit adequate improvement of shortness of breath, with return to normal baseline respiratory rate and depth within 48 hours. (We have to have an exact time frame)
Then- Long term goal- maybe
will exhibit movement of air in lower lung fields, with effective cough mechanism within 5 days
adequate oxygenation/ventilation AEB O2 sat of 95% or greater
Any thoughts? Please help!!
Last edit by newby09 on Sep 30, '09