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Melissa Wise Nursing 217 Planning/Implementation/Evaluation Patient Room: 14 B Med/Surg Nursing Diagnosis: Impaired gas exchange r/t inflammatory process of the lungs and ineffective cardiac pump AEB O2 Sat 93% with Venti mask at 31% oxygen. Long-Term Goal: Patient will regain adequate gas exchange. Outcome Criteria Interventions 1. Patients BP will be 120/80, HR will be 60-80 bpm regular rate and rhythm, Respirations 12-20 unlabored and O2 saturation > 95% as assessed q4h and PRN 1. Assess vitals q4h and PRN 2. Patient’s lung sounds will trend to clear as assessed q4h and PRN 2. Assess lung sounds q4h and PRN 3. Patient will remain alert & respond appropriately q4h and PRN 3. Monitor LOC q4h and PRN 4. Patients chest xray will be clear, showing no patchy opaqueness as ordered 4. Monitor chest xray results as ordered Rationale Evaluation 1. Assessing vital signs frequently will give the nurse an implication of the patient’s current health status and to quickly notice any change in patient’s condition. Hypoxia symptoms occur when inadequate oxygen reaches the tissues of the body. Increases in heart rate, respiratory rate and blood pressure are early signs that the body is not getting enough oxygen. O2 saturation is a quick noninvasive way of telling us if enough gas exchange is occurring. RR will increase to get the patient to inhale more O2, HR will increase as the heart attempts to pump blood faster to vital organs to get them more oxygen, and BP will increase due to vasoconstriction of vessels as the body goes into fight or flight mode. Early signs of hypoxia are a good indicator that the patient has impaired gas exchange. Patient has impaired gas exchange because of the inflammatory process of the lungs and an ineffective cardiac pump, therefore it is important to monitor vitals to catch any changes in a timely manner. P&P 445;821-823 2. Normal lung sounds should be clear over the posterior and lateral thoraxes. Three types of breath sounds are expected in various parts of the thorax: vesicular, Bronchovesicular, and bronchial. Adventitious lung sounds such as wheezing, crackles/Rales are a good indicator that the patient may be having impaired gas exchange. Changes in lung sounds may reveal the etiology of impaired gas exchange. Patient was diagnosed with pneumonia and pulmonary edema, Assessing lung sounds will help determine the effectiveness of the medications that are being administered. (Lasix, Spironalactone, and Levoquin should all show an improvement in lung sounds) Also on admission, patients BNP was 863, an increase in adventitious lung sounds would indicate worsening heart failure. NCP 437 3. A change in mentation such as increased confusion, restlessness, or decrease in level of consciousness is an early signs of hypoxia meaning that the patient’s brain is not getting enough oxygen. It is necessary that the brain receives enough oxygen to keep the patient alert and oriented as well as to carry out vital body functions to keep the patient alive. By assessing for these things at every interaction the nurse can detect earlier where there is a problem with gas exchange and plan interventions to prevent any further decline. Patient was admitted for SOB and admitted to “blacking out” in his car which are both indicators that he has impaired gas exchange. 4. A chest x-ray is a painless, noninvasive test that takes a picture of the structures inside your thoracic cavity such as your heart and lungs. It is used to screen, diagnose, and evaluate changes in the respiratory system. A chest x-ray was important for my patient because he was admitted with syncope, his BNP on admission was 863, and his lung sounds had coarse crackles in the bil bases. Having a chest x-ray would help differentiate whether it is a cardiac and respiratory issue that is causing his impaired gas exchange. His CXR showed patchy opaqueness and helped to diagnose him with pneumonia. It would be important for the physician to order another chest x-ray prior to discharge to see how the pneumonia is clearing up seeing as the patients O2 sat is only 93% while receiving O2 via venti mask at 31%. Lewis pg 513 1. Outcome partially met Patients BP was 108/65 HR was 73 and regular, Respirations 20 unlabored, and O2 sat was 93% with the venti mask on at 31%. I did encourage the patient to take deep breaths and to use his incentive spirometer Plan is ongoing 2. Outcome not met. Lung sounds were clear in BIL upper lobes, but there were course crackles in both bases. I encouraged TCDB and incentive spirometer Plan is ongoing 3. Outcome met Patient remained A&O x3 during every interaction Plan is ongoing 4. Outcome not met Patient’s chest x-ray showed patchy opaqueness, likely pneumonia. He is still receiving antibiotics. Also encouraged TCDB and IS Plan is ongoing Melissa Wise Nursing 217 5. Patients WBC will trend downward to 5,000 - 10,000 within 24 hours of administration of Levofloxacin. 5. Dependent Administer Levofloxacin in D5W 750 mg IVPB q48h per MD order 5. Levofloxacin (Levaquin) is a fluoroquinolone (anti-infective) used in the treatment of bacterial infections of the respiratory tract, including pneumonia. It inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme, causing the death of susceptible bacteria. The time it takes to completely resolve the infection depends on the organism and the site of the infection. The patients CXR showed patchy opaqueness in the LLL and possibly the RLL. He also had coarse crackles in the bilateral bases as a result of the combination of infection and pulmonary edema, and his WBC count on admission was 19.2. If the anti-infective is working properly you should see a decrease in his WBC count. As the infection subsides there will be a decrease in the inflammatory process in his lungs which will help improve his gas exchange. Davis Drug Guide online 6. Patients WBC 6.Independent 6. A Complete Blood Count (CBC) is used to assess the patient for anemia, infection, will trend Monitor CBC inflammation among other things. A CBC is a series of different tests used to evaluate the downward toward daily blood and cellular components of the red blood cells, white blood cells and the platelets. The 5,000-10,000 white blood cell count is the total number of the five types of leukocytes present in 1mm3 of within 24 hours of blood. The leukocyte count is a general indicator of infection, tissue necrosis, or inflammation. administration of The elevated value of WBCs occurs in response to infection and is usually directly Levofloxacin. proportionate to the degree of bacterial invasion. The normal WBC range at this agency is 5,000-10,000. The patient was diagnosed with pneumonia, therefore it is important to monitor his WBC count to ensure that the antibiotic that is being administered is actually working and show a decline in his WBC count. Lab and Diagnostic tests 222-224 7. Patient will have 7. Dependent 7. Administering supplemental O2 increases the partial pressure of O2 in inspired air. The an O2 sat of 92% Administer O2 2- goals for O2 therapy are to reduce the work of breathing, maintain the PaO2, reduce the on RA as 6 L/min to keep workload of the heart, and to keep SaO2 greater that 92%. O2 therapy will supply the patient 2 assessed q4h O sats > 95 % with adequate oxygen help maximize the oxygen carrying ability of the blood. Patient has and PRN coarse crackles in the bilateral bases of his lungs. Gas exchange at the alveolar level can be compromised because of copious excretions as well as the inflammatory process. Lewis p 612; 618-619 8. Patient will have 8.Independent 8. Elevating the HOB while the patient is laying down facilitates breathing by maintaining an O2 sat of 95%- Keep HOB abdominal organs away from diaphragm. This allows for better contraction and expansion of 100% with elevated while diaphragm allowing for better lung expansion leading to increase in alveolar gas exchange. optimal lung in bed Patient was diagnosed with pneumonia and showing signs of impaired gas exchange, therefore expansion while it is important to implement interventions to help him have optimal lung expansion until the in bed. infection is resolved and the inflammatory process has stopped. 5. Outcome not met Patient’s WBC count has decreased from 19.2 on admission to 14.6, but is still not WNL. Patient is still receiving antibiotic q48h Plan is ongoing 6. Outcome not met Patient’s WBC count has decreased from 19.2 on admission to 14.6, but is still not WNL. Patient is still receiving antibiotic q48h Plan is ongoing 7. Outcome not met Patient received continuous oxygen at 31% per venti mask and O2 sat was only 93% Plan is ongoing 8. Outcome not met Patient did have the HOB elevated while he was in bed, however his O2 sat was 93% with the venti mask on at 31%. I encouraged deep breathing and IS Plan is ongoing Melissa Wise Nursing 217 9. Patients BNP will be < 100 pg/mL as assessed on admission 9. Assess serum BNP on admit 10. Patient’s secretions will be thin and easily expectorated 2-4 hours after administration of Guaifenesin 10. Dependent Administer Guaifenesin 600 mg PO bid per MD orders 11. Patients lung sounds will trend to clear clear by day 2 11. Dependent Administer Furosemide 20 mg PO qday 12. Patients lung sounds will trend to clear clear by day 2 12. Administer Spironolactone 25 mg PO qday 9. Natriuretic peptides (atrial natriuretic peptide [ANP] and b-type natriuretic peptide [BNP]) are hormones produced by the heart muscle that promote venous and arterial vasodilation (thus reducing afterload and preload).The release of BNP is triggered by increased pressure, especially in the left ventricle. BNP levels have been shown to be significantly increased in patients with HF. Left-sided failure results from left ventricular dysfunction, which prevents normal blood flow and causes blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium and then the alveoli, which manifests as pulmonary congestion and edema. On admission patients BNP level was 863 pg/mL (normal BNP should be < 100 pg/mL) which indicates that his heart was not working as effectively as it should. It is important to monitor BNP along with a chest x-ray to determine if the patients impaired gas exchange is related to a cardiac issue or respiratory issues. Lewis p 800-805 10. Guaifenesin is an expectorant that is administered to decrease viscosity of secretions by increasing respiratory tract fluid. It should be taken with a full glass of water to help further decrease viscosity of secretion. An expectorant will help clear secretions made from the inflammatory response as it relates to the patients diagnosis of pneumonia. This will help improve gas exchange by decreasing fluid in the lungs allowing for increased lung expansion. Per other nursing assessments in the patients chart, it was documented that he had thick secretions and a productive cough. However, I assessed his cough to be dry and non-productive. He is also currently receiving Lasix, Spironolactone, and Levofloxacin to help decrease the congestion in his lungs. Davis Drug Guide Online 11. Furosemide (Lasix) is a loop diuretic that inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. It increases secretion of water, sodium, chloride, magnesium, potassium, and calcium. Loop diuretics cause greater diuretics than thiazide or potassium sparing diuretics. Patient was admitted with pulmonary edema and has been diagnosed with pneumonia; therefore it is important to use diuretics to help reduce the amount of congestion in his lungs secondary to pulmonary edema which is causing impaired gas exchange. It is important to monitor his lung sounds to determine if this intervention is in fact helping the problem. Patient also has a history of HTN and by administering the Lasix this will help lower his BP and reduce the workload of his heart. Davis drug guide online 12. Spironolactone (Aldactone) is a potassium-sparing diuretic. It causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone. Patient was admitted with pulmonary edema, pneumonia and had a BNP level of 863. It is important to remove the excess fluid so that his heart is able to pump more effectively, as well as reduce the congestion in his lungs to ensure adequate gas exchange. Patient also has a history of HTN, the combination of diuretics and Metoprolol will help reduce the workload of his heart. Davis Drug guide online 9. Outcome not met Patients BNP level on admission was 863 pg/mL Since then he has received Lasix, Spironolactone, and Levofloxacin to help remove the extra fluid and infection in his lungs. BNP drawn 2 days later was 93. Plan is ongoing 10. Outcome not met Patient did not produce any sputum during my shift. In addition to the medication, I encouraged TCDB and use of incentive spirometer Plan is ongoing 11. Outcome not met Patient had coarse crackles in the bilateral bases of his lungs. I did encourage TCDB and IS and he is still receiving levofloxacin Plan is ongoing 12. Outcome not met Patient had coarse crackles in the BIL bases of his lungs. I encouraged TCDB and IS. He is also still receiving Levofloxacin Plan is ongoing Melissa Wise Nursing 217 13. Patient will have increased tidal volume with administration of Ipratropium Bromide Solution qid 14. Patient will see cardiologist for follow up appointment with in one week of discharge 13. Dependent Administer Ipratropium Bromide solution 0.5 mg/2.5 ml qid 15.Patient will demonstrate proper use of incentive spirometer to a volume of 1200 mL q1h while awake Teach patient proper use of incentive spirometer q1h while awake 14. Collaborate Assist patient to set up consult with cardiologist after discharge 13 Ipratropium Bromide solution is a bronchodilator / anticholinergic drug that is delivered by the inhalation and intranasal routes. It inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentration of cGMP. Decreased levels of cGMP produces local bronchodilation. Patient has been diagnosed with pulmonary edema and pneumonia. It is important to administer a bronchodilator to ensure there is no airway constriction that will add to his impaired gas exchange. Administration of a bronchodilator will also help increase his tidal volume. Davis Drug guide online 14. A cardiologist is a physician specializing in the treatment of heart disease. It is important for the patient to follow up with a cardiologist to ensure that his heart is functioning at its full capacity to prevent future hospitalizations. Currently the patient has an ineffective cardiac pump which has caused pulmonary edema and impaired gas exchange. It is important for the patient to be on the proper medication regimen and preventive measures to prevent any further decline in his heart condition. On admission his BNP was 863 (normal is 0-100) This is evidence that his heart was working much harder than it should be. 15. Respiratory muscle training improves muscle strength and endurance, resulting in improved activity tolerance and helps prevent respiratory complications. One method for respiratory muscle training is the use of an incentive spirometer (IS). The purpose of using the IS is to expand alveoli, increase tidal volume, and prevent atelectasis & pneumonia. You take a deep breath, exhale, then place lips tightly on the mouthpiece. Inhale deeply and slowly through the mouth piece watching speed monitor & balls, bubbles or diaphragm depending on the model being used. Then exhale. This should be done 5-10 time per hour while awake. Patient was diagnosed with Pneumonia, therefore it is important for him to properly use the incentive spirometer every hour to help expand the alveoli and to improve his gas exchange. P&P p.854; class notes 13. Outcome not met Patient’s lung sounds continued to have coarse crackles in the bil bases. I encouraged TCDB and IS Plan is ongoing 14. Outcome met Patient has not been discharged or seen cardiologist at this point Plan is ongoing 15. Outcome met I did visualize the patient properly using the incentive spirometer multiple times throughout my shift. He was able to reach the level of 1200mL. Plan is ongoing Melissa Wise Nursing 217 Psychosocial Need Prioritized Psychosocial Nursing Diagnosis: Risk for anxiety r/t changes in health status Long-Term Goal: Patient will show no signs of anxiety Outcome Interventions Rationale Criteria 1. Patient will identify/verbalize anxiety as it happens 1. Assist patient in identifying s/s of anxiety now 2. Patient will verbalize 3 adaptive coping mechanisms after 1:1 2. Teach patient adaptive coping mechanisms now 3. Patient will demonstrate at least one relaxation technique after 1:1 3. Teach relaxation techniques as needed 4. Patient will list 2 people for a support system now 4. Help identify support system for patient now 1. Anxiety often manifests as a vague, uneasy feeling or discomfort. It is quite unpredictable and can sometimes become debilitating to the patient. Some physiological characteristics of anxiety include dizziness, perspiration, frequent urination, palpitations, dry mouth and restlessness. Behavioral characteristics include feeling of helplessness or inadequacy, crying, difficulty concentrating and preoccupation. It is important for the patient to be able to identify signs and symptoms of anxiety as they occur so that he can use proper coping mechanisms or relaxation techniques. It appears that he has been fairly healthy up until this point. His recent diagnosis of pulmonary edema and pneumonia could cause increased anxiety because he will not be on more medications at home when he leaves the hospital. He also had a pretty extensive nose bleed that could cause anxiety thinking that it may occur again. 2. Coping is the person’s effort to manage psychological stress. Effectiveness of coping strategies depends on the individual’s needs. A person’s age and cultural background influence these needs, which is why no single coping strategy works for everyone or for every stressor. Positive techniques include: seeking a social support system, adequate nutrition, sleep, and exercise. Maladaptive coping mechanism we want the patient to refrain from are alcohol or smoking, self-medicating, or disassociation with friends and family. After this hospitalization there is a chance that he is going to go through some lifestyle changes at home and it’s important for him to use adaptive coping mechanisms to help him through this tough time 3. Some relaxation techniques are deep breathing, yoga, meditation, guided imagery, progressive muscle relaxation and music/art therapy (among others). It is important to identify relaxation techniques that would be beneficial to the specific patient seeing as everyone finds different activities to be relaxing to them on a personal basis. Because his body is going to be weak after this recent hospitalization, it is going to be important for him to use relaxation techniques to help manage any anxiety he may encounter. 4. Having a strong support system after hospitalization can make a huge difference in the patient’s recovery and can be critical to helping one get through the stress of tough times. This patient will likely be discharged on more medications that he came in with and there is a strong possibility he will have to make some follow up appointments to ensure that the pneumonia and pulmonary edema have resolved as well as to have a check up to ensure adequate heart function. Evaluation 1. Outcome partially met Multiple times through-out the shift the patient seemed to be preoccupied with the thought of his nose bleeding again and wondering what caused it. He did not however verbalize that he was anxious about it Plan is ongoing 2. Outcome not met Patient did not verbalize 3 coping mechanisms. He had company for the majority of the night and was pre occupied Plan is ongoing 3. Outcome not met Patient did not demonstrate relaxation techniques. He had company for the majority of the night and was pre occupied Plan is ongoing 4.Outcome not met Patient did not list 2 people for a support system. He did however have visitors for the majority of the night. Plan is ongoing