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).

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: < 3 seconds in hands and feet

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

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

<0.8

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

<0.4

BNP

<100 pg/mL

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 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:

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)

(S

pecific,

M

easurable,

A

ttainable,

R

ealistic,

T

ime 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)

(S

pecific,

M

easurable,

A

ttainable,

R

ealistic,

T

ime 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)

(S

pecific,

M

easurable,

A

ttainable,

R

ealistic,

T

ime 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.