Focused Assessment

ABCs:





ï€

Airways

: this patient has an airway obstruction as he has a history of COPD. This patient’s airflow may also be limited by the thick secretions as he has a productive cough. Close monitoring is required to assess his airway clearance, by checking the mouth, monitor the amount of sputum, auscultating the lung sound.




Breathing

: this patient’s breath pattern is already abnormal as he has dyspnea, shortness of breath, orthopnea, he refuses to lie down, shallow labored respirations, RR 30, and SpO

₂

86%. The breathing pattern need to be monitored closely to see it turns better or worse during the treatment. The nurse needs to count the RR, checking the SpO

₂

, and observing the breathing pattern every 15min.




Circulation

: the patient’s pulse is 115 which is regular for the patient. His BP is 135/90, little higher. His skin is pale with visible peripheral cyanosis. He has mild pedaled edema, but denies calf tenderness or swelling. Therefore, the nurse needs to assess the circulation, such as by checking the capillary refill, assessing the JVP, nail bed, peripheral pulses. Besides that, the nurse also needs to pay attention to the potential MI as this patient has a history of angina, a family history of MI, and the heart loads increased by the lower SpO

₂

, higher BP and HR.

VS and pain:


BP: 135/90, HR: 115 regular, T: 38.6

^o

C po, RR: 30; SpO

₂

86% with RA. This patient’s BP, T, and RR are higher than normal, and the SpO

₂

is lower than normal. The nurse needs to assess those vital signs every 15mins to see the change in trend. The patient complains of Sternal chest pain, but states it is not typical of his angina. The nurse needs to assess the pain by using the PQRST and to ask whether the pain is tolerable or not. This assessment determinates the later pain management.

CNS



:

There doesn’t have much information about this patient’s CNS status. Therefore, the nurse needs to assess this patient’s awareness and orientation to time, place, and person. The nurse also need to assess the patient’s command following, vision, and hearing. It is known that this patient appears anxious and tremulous. Nurse need to ask the causing of anxious during the assessment.

CVS




:


Assess the cardiac rhythm by auscultating apical pulse, S1, S2, S3, S4 valve area, as this patient has a history of angina and HTN. If it is necessary, the nurse may need to apply the ECG monitor. Assess the peripheral edema, especially in the lower extremities as he has calf tenderness or swelling. Assess the JVP. Assess the dorsalis pedis and post tibial pulse. Assess the peripheral cyanosis. The nurse needs to assess the potential angina and MI too.

Resp:


The patient has dyspnea, shortness of breath, orthopnea, productive cough, he refuses to lie down, shallow labored respirations, RR 30, and SpO

₂

86%. He has a history of COPD. Nurse needs to assess the RR and SpO

₂

every 15 mins, as well as those breath patterns. Assess the causing of the shallow labored respirations and SOB. Assess the sputum’s characters, such as amount and color change. Auscultate all lung fields to check the breath sounds, identify the adventitious sounds, such as crackles, wheeze, stridor, pleural rub, and rhonchi. Inspect the shape and configuration of the chest wall, and the symmetrical expansion. Tactile fremitus bilaterally and assess diaphragmatic excursion. The nurse may suggest the chest X-ray, CT test, and sputum culture as this patient on the risk of lung infection.

GI




:


The patient has anorexia and vomiting, which may lead to malnutrition and result in the weakness of respiratory muscles. Assess the strength of the muscles. Assess his vomiting frequency, stimuli, amount, and color (checking GI bleeding). Assess his diet and fluid intake. Inspect his abdominal contour, symmetry, and umbilicus. Auscultate abdominal bowel sounds. Light palpate abdominal for soft, tenderness, and pain. Ask for the bowel movement frequency, amount, and color.

GU



:

 There is no information about this patient’s GU status. A nurse can assess his ability to void, continence or incontinence. Assess urine for the clear, pale, odourless, discomfort, amount.

Integ



:

The patient has visible peripheral cyanosis, fever, and diaphoretic. The nurse needs to keep monitoring these symptoms. Besides that, assess the skin color, moisture, lesions, skin turgor, and sensory perception.

Labs/DI:





The patient’s ABG: ABGs: pH 7.28; PaCO

₂

60 mmHg; HCO

₃

25; PaO

₂

85 mmHg; CBC: HgB 189 mmol/L; Hct 49%; WBC 19 x 10

⁹

/L. This patient has uncompensated acute respiratory acidosis as his pH≤7.35, his PaCO

₂

≥ 45mmHg, and his HCO

₃

within the normal range of 22~26 mEq/L. His PaO

₂

≤ 90~100mmHg. This patient’s HgB ≥ 140~174 g/L, the Hct is within normal range, and the WBC≥ 4.8-10.8 x 10

⁹

/L. The higher WBC indicates infection. The higher HgB may due to the compensation of the long-term low SpO

₂

which caused by the COPD.



Due to the suspect of infection (evidenced by the fever and WBC), nurse may need to facilitate the specimen collection of sputum for the lab test.



Due to the daily use ASA, nurse needs to assess the blood work of PTT and INR.

Meds:





ASA: Aspirin for the angina; belongs to antiplatelet drugs; has nausea, vomiting, heartburn side effects, contraindicate for people has bleeding.



Ramipril: to treat HTN; belongs to the ACE inhibitor drugs; has cough, vomiting, weakness, headache side effects.



Furosemide: to treat HTN and to reduce the welling and fluid retention; belongs to the diuretics drugs; has muscle cramps, weakness, dizziness, confusion, thirst, upset stomach, vomiting side effects.



Pantoprazole: to treat GERD; belongs to proton pump inhibitors; has headache, nausea, vomiting, gas, joint pain, and constipation side effects.



Nitro-Dur spray: to treat episodes of angina; belongs to the organic nitrate drugs; has flushing lightheadedness, dizziness side effects.



Symbicort: to treat the narrow of airway and inflammatory; is the combinations of Budesonide and Formoterol; has the upset stomach, cough, dry mouth side effects.

ï€

Albuterol: to treat wheezing, SOB, COPD, and the diseases affecting lungs and airways; belongs to beta2-adrenergic agonists; has the uncontrollable shaking of a part of the body, nervousness, headache, nausea, vomiting, cough, throat irritation side effects.



Based on the assessment of Meds function and side effects, it is noted that the majority drugs the patients is using have the side effects of nausea, vomiting, heartburn, upset stomach, cough, weakness, headaches. The patient currently has the cough and vomiting symptoms. Therefore, the nurse may need to report to the physician to stop taking those medications and finding other replaceable medications, especially for the Albuterol puffer. The patient admits to using Albuterol puffer “almost continuously” over the past 8 hours with minimal effect. The nurse needs to ask the patient to try to stop using the Albuterol as it is overdose and has less effect, and reports that to the physician.

Nursing history:


 It is already known that this patient quit smoking 2 years ago, but previously smoked 2 packs a day for 40 years. He has a current health history of Angina, COPD, HTN, GERD and Type 2 diabetes (diet controlled). This patient also has been hospitalized in the ICU 2 years ago “because he had a problem with his chest”. His father died from an MI at the age of 55. During the assessment, the nurse need to assess this patient other history, such as alcohol abuse, drug abuse, and occupations. The nurse may need to ask whether the patient can remember the initial symptoms of angina, which will help him to predict the potential coming of angina. Nurse needs to assess how the patient usually deals with his COPD, HTN, GERD, and DMT2.

Nursing Diagnosis


(list 3 according to NANDA with rationale or evidence)



Ineffective airway clearance related to thick secretions and airway inflammation as evidenced by productive cough, dyspnea, COPD, shortness of breath, shallow labored respirations, sternal chest pain, fever, and the increased WBC 19 x 10

⁹

/L.



Ineffective breathing pattern related to pain and position as evidenced by the sternal chest pain, refuses to lie down, will only sit on the side of the bed, shortness of breath, tachypnea, shallow labored respirations (use of accessory muscles).

ï€

Impaired gas exchange related to alveolar hypoventilation as evidenced by PaCO

₂

60mmHg ≥ 45 mmHg, pH 7.28≤7.35, PaO

₂

85 mmHg≤ 90-100mmHg, SpO

₂

86% with RA, pale with visible peripheral cyanosis, and diaphoresis.

Nursing Interventions

I) Nursing interventions relate to the diagnosis of ineffective airway clearance



Monitor respiratory rate, rhythm, depth, and effort of respiration.



Contact doctor to order alternative bronchodilators (Albuterol not works effectively anymore for him), and administer the new ordered bronchodilators to open the airways as he has COPD.



Teach effective cough techniques to clearance of retained secretions.



Ensure fluid intake is adequate to liquefy secretions to facilitate removal.



Assist patient to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed to improve respiratory status.



Auscultate lung sounds closely after treatments to check the improvement.

II) Nursing interventions relate to the diagnosis of ineffective breathing pattern

ï€

Assist patient in a comfortable position, such as tripod position, sitting up, or elevated back rest. This position also can reduce the respiratory efforts and then reduce oxygen needs. Also teach the patient wife how doing it.



Give patient support of his upper extremities to maximize respiratory excursion.



Use optimal pain control measures to promote deep breathing, turning, and coughing.



Teach patient deep breathing to maximize use of the diaphragm when pain is tolerable.



Teach pursed-lip breathing to prolong the exploratory phase and slow respiratory rate.



Assess respiratory rate and pattern and auscultate lungs every 2-3 hr to evaluate the rate, quality, and depth of patient’s respirations.



Monitor the manifestations of complications, such as pneumothorax, hemothorax to allow early detection.

III) Nursing interventions relate to the diagnosis of impaired gas exchange



Administer O

₂

therapy to treat hypoxemia and increase SpO

₂

saturation.



Monitor respiratory rate and oxygenation status to prevent the over oxygenation.



Monitor the signs and symptoms of hypercapnia, such as confusion, somnolence, headache, irritability, and decrease in mental acuity, increase in respiration, facial flush, and diaphoresis, to assess the change trend.



Teach to avoid central nervous system depressants as they can depress respirations.

IV) Other nursing interventions relate to the patient illness



Facilitate the infection test, such as prepare the sputum specimen.



Contact physician to order MEDs for the fever and vomiting, and administer the MEDs.



Monitor the potential occurrence of angina.

4)

If the physician diagnosed infections, such as pneumonia, and ordered antibiotic medications for that, the nurse needs to administer these MEDs.

ï€

As mentioned in the MEDs assessment, the patient has the symptoms of cough and vomiting, which are the side effects of the majority of the medications. Therefore, the nurse needs to report these findings to the physician and ask for alternative medications. The nurse also needs to report the less the effect of Albuterol to the physician and ask for replacement.



To facilitate the communication with patient, nurse needs to ask his wife or other translator to translate as his English is limited.

Ethical Considerations

Ethic issue is another important area for the nurses to consider during the nursing process. In this scenario, nurses need to show their competency by correctly assessing the patient signs and symptoms. Nurses need to show their accountability by documenting their assessments and reporting the abnormal findings to the doctor. Nurses need to show their empathy as the patient is suffering from the difficult breathing. Before any nursing interventions, nurses always need to get the informed consent from the patient. Nurses also need to keep awareness that the patient has the right to refuse interventions. For example, the patient has right to refuse to lie down, or to take some medications. During the nursing intervention, nurses need to show their respect to the patient and protect his human dignity. Nurses have the responsibility to take care of this patient and to help him to have an effective breathe pattern. During the caring process, nurses also need to keep the patient’s privacy and confidentiality. It is also important for nurses to keep the principles of justice and fairness during the nursing care, such as having enough time to stay with this patient. As this patient’s English is limited and his wife provides information, nurses need to assess whether his wife’s interpretation represents the patient’s interests. Nurses may also need to find other translators when his wife is not able to show up. This patient has acute respiratory failure as he has SOB, cough, dyspnea, orthopnea, and low SpO

₂

level. He also has a history of angina and a family history of MI. Therefore, it is important for the nurse to get the advanced direction, such as DNR.

Nursing Theorist

According to the Roy’s Adaptation Model, person is a biopsychosocial being who is constantly adapting to the changing environment. There are four modes of adaptation: physiological, self-concept, role function, and interdependence. In the Model, Roy also divided the nursing process into six dynamic steps: assessment of behavior, assessment of stimuli, nursing diagnosis, goal setting, intervention, evaluation. Here, the physiological adaptive mode is picked to guide the nursing care for Lorenzo Stipo, as there are not enough available information for the other three modes in this scenario.

Physiological adaptive mode guides nursing care to focus on the physiology responds to the stimuli from the environment. In this scenario, Lorenzo’s health problems are complex as he has several chronic diseases and acute diseases.

1)

Assessment of Behavior: Lorenzo has a productive cough, SOB, dyspnea, orthopnea, fever, and sternal chest pain. His RR is 30 and SpO

₂

is 85% with RA. He refuses to lie down and will only sit on the side of the bed. He appears tachypneic with shallow labored respirations. He is diaphoretic and pale with visible peripheral cyanosis.

2)

Assessment of stimuli (related to observed behavior): the focal stimulus for Lorenzo’s SOB, dyspnea, and orthopnea is the acute lung infection (need further medical diagnosis). Contextual stimuli include the vomiting and history of GERD. The residual stimuli are the 40 years smoking history and COPD.

3)

Nursing diagnosis: Ineffective breathing pattern related to infection, vomiting, and COPD.

4)

Goal setting: improve patient’s breath pattern evidenced by having a respiratory rate of 12-18/min and SpO

₂

more than 90%.

5)

Intervention: teach the patient deep breathing to maximize use of the diaphragm when pain is tolerable. Teach patient to have a tripod position for breath. Teach patient pursed-lip breathing to prolong the exploratory phase and slow respiratory rate. Hold on the current medications and contact with the doctor as the cough and vomiting are the common side effects of these medications. Administer oxygen therapy to the patient. Contact the doctor to assess the potential lung infection and prescript some antibiotics. Administer these antibiotics to the patient and also teach the patient or his wife about how to administer these antibiotics at home.

6)

Evaluation: Lorenzo will know how to breathe effectively by applying these breathing techniques. His respiratory rate will be within 12-18 breaths/min and his SpO

₂

more than 90%