queensj

i posted my careplan somewhere on page 2 of this thread. prioritizing per maslow's.. i wanted to fix breathing/gas exhange first d/t low O2....with dx Pneumonia ( i know i have been saying pleural effusion but the primary dx is PNA ) I can only have 3 physiological, 1 psychological and 1 social nursing dx.. Impaired Gas Exchange RT changes in the alveolar-capillary membrane, deficit in oxygenation and CO2 elimination of the alveo-capillary level AMB abnormal ABG, rapid and shallow respirations of 22-23 per min. [breathing is #1 priority] Acute Pain RT stage II decubitus ulcer on coccyx and R buttock AMB grimacing during repositioning [pain needs to be stabilized b/c pain increases bp, hr, and resp, which will further jeopardize ABGs] Impaired Skin Integrity RT cut in the L lateral chest due to hx of chest tube insertion [pt has low WBC which makes it difficult for her to heal] Anxiety RT situational crisis of pt whenever sister leaves bedside AMB pt screaming sister's name continuously until pt gets tired

Patient’s initial___H,J________Room # __186 ICU__Medical Diagnosis _PNA, Resp Distress___ Nursing Diagnosis: Impaired Gas Exchange RT changes in the alveolar-capillary membrane, deficit in oxygenation and CO2 elimination of the alveo-capillary level AMB abnormal ABG, rapid and shallow respirations of 22-23 per min. [TABLE] [TR] [TD=width: 182] Assessment (Subjective & Objective) [/TD] [TD=width: 176] Planning/ Outcome [/TD] [TD=width: 187] Interventions & Rationales [/TD] [TD=width: 179] Evaluation [/TD] [/TR] [TR] [TD=width: 182] Subjective: ??? Objective data: -shallow/rapid respirations of 22-23/min -diminished lower lobe lung sounds bilat upon auscultation -O2 saturation of 90% when pt removes NC & 93% on 2L O2 via NC -ABG as follows ph: 7.288 (7.35-7.45)acid pCO2: 53 (35-45)-acid pO2: 75.3 (80-100)hypoxia hCO3: 24.5 (22-26)wnl [/TD] [TD=width: 176] Short-Term Goal: Patient will have O2 saturation of >90% within 1 hour Long-Term goal: Patient will demonstrate improved ventilation and oxygenation of tissues with blood gas analysis within normal range of Ph(7.35-7.45) pO2 (80-100) pC02 (35-45) HCO3 (22-26) & maintain respiration of 16-20/min(pt's usual range) with regular respiration, rate, rhythm, and depth, within 12 hours/by the end of shift [/TD] [TD=width: 187] 1. Administer supplemental O2 per MD order To promote oxygenation and increase arterial O2 (Lewis p.552) 2. Monitor effectiveness of O2 therapy by checking pulse ox Pulse ox is useful to detect changes in O2 3. Elevate HOB 30-45° continuously for maximum chest expansion (Gulanick,Myers p. 480) 1. Monitor ABGs every 2 hrs and maintain ABG of Ph(7.35-7.45) pO2 (80-100) pC02 (35-45) HCO3 (22-26) ABG will facilitate alteration in pulmonary therapy and provide information about developing hypoxemia and respiratory acidosis. Decreased O2 and increased CO2 are signs of respiratory failure 2. Assess respirations every 2 hours, note quality (effortless resp), rate(16-20), rhythm(rapid/slow), depth(shallow/deep) and position assumed for easy breathing(30-45°) Pt will adapt their breathing patterns over time to facilitate gas exchange. Both rapid, shallow breathing patterns affect gas exchange 3. Auscultate lung sounds in all fields every 2 hours To obtain data on pt's response to therapy and check for newly [/TD] [TD=width: 179] Goals met: Patient's O2 saturation increased to 97% with 2L o2 via NC. Pt remained in high fowlers position within the hour Goals partially met: 0730 Ph:7.28(7.35-7.45)acid pO2: 75.3(80-100) pC02: 53 (35-45) HCO3: 24.5(22-26) 1000 Ph:7.33 (7.35-7.45) acid pO2:70.1 (80-100) pC02: 47.6 (35-45) HCO3: 24.5 (22-26) Pt's pO2 dropped, pCo2 improved, hco3 remained normal limits, and pH improved. Pt gets irritated when sister leaves, and takes out her NC/pulse ox which led to decreased oxygenation. The pt however, started relaxed breathing, no s/s of rapid/shallow respirations and maintained RR of 20/min when on 2L o2. MD notified, new order for Mitt restraints noted. [/TD] [/TR] [/TABLE] Revised/Approved 5/14/2014

meds: Ascorbic Acid/vit C 500mg po BID Brimonidine/alphagan 0.1% eyedrops 1 drop on left eye BID Carvedilol/coreg 12.5mg po BID with meals Cholecalciferol/vit d-3 2000 units po at bedtime clopidogrel/Plavix 75mg po daily famotidine/pepcid 1 tab po daily ferrous sulfate 1 tab po TID before meals pilocarpine 2% eyedrops on left eye fourx daily xenaderm 1 app to coccyx/buttock 4xdaily regular insulin/humulin r 100units/mL ing per sliding scale amlodipine/norvasc 5mg po daily oxycodone/oxyir 1 tab po once prn pain 7-10 magnesium sulfate/citrate of magenisa 300mlpo for constipation docusate/colace 10ml gtube

-73 y/o female V/S as follows: 36.9,hr 101, rr 20 with 4L oxygen, 22 without O2, BP 176/86 106lbs, 5'2, BMI-19 AAO only to person, had to reorient to place and time -pt is blind on R eye dt retinopathy -no teeth, no dentures, has difficulty swallowing [clear liquid diet] -on BiPAP[on and off depending on pt], and on 4L O2 when off bipap -rapid and shallow respirations of 22-25/min when pt gets irritated/removes NC/Bipap -glasglow coma scale - 13 verbal inapprorpiate words, you can't have a conversation with her but she will follow commands such as drinking water or repositioning -bronchial/bronchovesicular lungs sounds clear on auscultation, diminished vesicular lung sounds bilat [also xray shows "white-out"?? on R side] - S1 S2 audible with no murmur -pulses 2+ bounding, cap refill -abd soft, nondistended, non tender, hypoactive bowel sounds on 4 quadrants, has ileostomy haven't had a bowel movement in 3 days, and it is poorly maintained. -pt has decreased appetite, and eats mostly medicine with yogurt. -pt was on f/c but removed d/t cloudy urine and suspected UTI -has L AKA , limited ROM bilat leg -stage ii decub ulcer on R buttock/coccyx area -skin dry/ashened, -L flank cut d/t s/p chest tube, n o redness no swelling Had thoracentesis d/t R pleaural effusion with 300mL exudate On and Off Pt restlessness and would take out O2, pulse ox when irritated pH 7.31[7.35-7.45] c02 47.6 [35-45] hco3 24.5[22-26] bun 28 [8-25] ca 10.4 [8.7-10.2] bs 169 Thank you for helping me and taking time explaining everything. Just by typing all my assessments made me start thinking of abnormal findings. I guess I was too busy matching what I am SUPPOSED to see based on the medical dx and failed to assess my pt more on deeper level. It is so difficult to assess especially when the pt is irritated and wants nothing to do with a student. My teacher expects me to know dates of past medical hx, but I couldn't even keep a conversation with the pt as she is always either resting or irritated. I came up with Ineffective Breathing pattern RT fluid in the pleural space AMB rapid and shallow breathing 22/min, restlessness, and diminished lung sounds bilat -i need 3 physiological nrs dx, 1 psychological and 1 social . still working on my other 4

I need to make a care plan but with so many dx she has on hx, I have no idea which one to work on. I NEED HELP!! IT'S MY FIRST CAREPLAN ON A REAL PT IN ICU! Chief complaint: acute on chronic respiratory failure, metastatic ovarian cancer to lungs with malignant pleural effusion, respiratory distress, and [supposedly PNA as per the RN that I was following told me but PNA is not on the chart] i have been juggling my primary dx between acute resp. failure and pleural effusion but I've done research that pleural effusion is only secondary to a disease, so I'm not sure if I can use this: Malignant R pleural effusion secondary to lung cancer AMB rapid respirations of 22-25/min and dyspea. The pt is Awake and alert to person but uses inappropriate words and always screaming when she wants her sister. I don't know how to chart subjective findings when she couldn't really verbalize anything but screaming.