Download Knowledge Preparation on Presenting Health

BSN Program Nursing Practice II
Student Advance Preparation for Nursing Practice: Expectations
Topic
When Started
Standard
Presenting
Health Challenge
Praxis Week 1
Clinical Week 2
Students will come to clinical having completed a standardized
template on the patient’s admitting/priority health challenge(s)
as validated by the Instructor. The template is attached.
Concurrent
Health
Challenges
Decision Making
Worksheet
Praxis week 1
Clinical Week 2
Students will come to clinical with a page on which each of the
patient’s concurrent health challenges are defined only.
Praxis Week 1
Clinical Week 2
Students will come to clinical with Anticipated Foci listed in
pencil and an assessment plan outlined within the system
assessment boxes on the back of the worksheet.
Medications:
Drug Guide
Clinical Week
4/Two weeks
prior to
medication quiz
1. For each of the medications your patient is receiving, flag
Medications:
Client Drug
Profile
Clinical Week 4
Two weeks prior
to medication
quiz.
and review the Drug guide
2. Use the Drug Guide to prepare the Client Drug Profile Card
(see the next section).
3. Bring the flagged Drug Guide to each clinical day.
4. Have the Drug Guide with you for reference as you prepare
the medications e.g. for checking safe dose and other
important details etc.
Students will come to clinical with a client specific medication
profile e.g. index card, in words understood by most clients that
identifies:
Nursing Responsibilities
(Including Major/Common Side
Drug Name Purpose/Action
Effects & Assessments)
1.
2.
3.
4.
5.
6.
Etc.
This information should be carried in the uniform pocket and
accessed as needed e.g. at the bedside.
Laboratory & Diagnostic Tests
Please note that students are NOT expected to come to clinical practice with evidence of having
researched and understood laboratory and diagnostic tests; this will be an expectation in Semester III
when pathophysiology courses have begun. In semester II, students are encouraged to be curious about
these tests and to consult with the instructor and staff about their use and the related nursing
responsibilities.
Sproule/Douglas/NPII/Student Clinical Prep
28/08/2010
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BSN Program Nursing Practice II
Knowledge Preparation on Presenting Health Challenges
Student
Health Challenge/Diagnosis: PLEURAL EFFUSION
***Please note that this research is standardized for any client with this health challenge and as such, once
completed can be re-used with any other client with this specific health challenge. In future semesters, additional
knowledge including pathophysiology and diagnostic tests will be expected.
Description/Definition
(in your own words)
Clinical Manifestations
-is a build-up of fluid in
the pleural space (area
between the two layersparietal and visceral
pleura- covering the lung)
-not a disease, but a sign
of a serious disease
Transudate/exudate:
-progressive dyspnea
-decreased movement of
chest wall on affected
side
-pleuritic pain from
underlying disease
-percussion reveals
dullness
-auscultation reveals
absent or decreased
breath sounds over
affected area
- Empyema has same
manifestations as above
but also includes:
-fever, night sweats,
cough, weight loss
3 classifications:
1) Transudate:
- occurs in
noninflammatory
conditions and is a buildup protein-less, cell-less
fluid that is clear or pale
yellow
2) Exudate:
-build-up of fluid and cells
in pleural space due to
increased permeability of
capillaries (due to
inflammation) – has a high
protein content and fluid
is dark yellow or amber
-fluid build-up of more
than 250mL will show up
on a chest xray
3) Empyema:
-pleural effusion that
contains pus
- either type can be
identified by a
thoracentesis (procedure
to remove fluid from
pleural space)
Sproule/Douglas/NPII/Student Clinical Prep
28/08/2010
Collaborative Care
(Medical, Pharmacological, Surgical etc Treatments)
Prevention:
 Main goal is to treat the underlying cause
which in turn helps relieve/ get rid of/
decrease pleural effusion. However
treatment of pleural effusions secondary to
malignant disease is a more difficult
problem they become recurrent and
accumulate quickly
Drug Therapy:
 Antibiotic therapy:
 Doxycycline
 Vibramycin
 Bleomycin
o All 3 help with sclerosing
 Talc (Appears to be most effective)
Surgical Therapy:
 Thoracentesis thoracentesis needle is
inserted into the intercostal space, fluid is
aspirated with a syringe, or by tubing that
leads into a sterile bottle – this is done to
determine what type of pleural effusion is
present
 Pleurodesis procedure that causes the
membranes around the lung to stick together
and prevents the buildup of fluid in pleural
space. An irritant (such as
Bleomycin, Tetracycline, or talc powder) is
instilled inside the space between the pleura
in order to create inflammation which
hardens the two pleura together
 Thoracoscopy medical procedure involving
internal examination, biopsy, and/or resection
of disease or masses within the pleural
cavity and thoracic cavity.
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BSN Program Nursing Practice II
Nursing Management
Nursing
Assessment
Past health hx:
-CHF, cancers, GI
disease, infections,
renal disease,
pneumonia, TB
Foci: Nursing
Diagnosis
1. impaired gas
exchange
2. activity intolerance
Respiratory:
-dyspnea
-fatigue
-decreased activity
-absent chest
sounds?
-cough
Cardiovascular:
-tachycardia
-edema
-BP?
3. decreased cardiac
output
Nursing Implementation
Nursing Interventions & Rationales
1.1 Monitor vital signs. With initial hypoxia and hypercapnia, blood
pressure (BP), heart rate, and respiratory rate all increase. As the
hypoxia and/or hypercapnia becomes severe, BP and heart rate
decrease, and dysrhythmias may occur. Respiratory failure may
ensue when the patient is unable to maintain the rapid respiratory
rate.
1.2 Administer medications as prescribed. The type depends on the
etiological factors of the problem (e.g., antibiotics for pneumonia,
bronchodilators for COPD, anticoagulants and thrombolytics for
pulmonary embolus, analgesics for thoracic pain).
1.3 Monitor chest x-ray reports. Chest x-ray studies reveal the
etiological factors of the impaired gas exchange. Keep in mind that
radiographic studies of lung water lag behind clinical presentation by
24 hours.
4. excess fluid volume
5.
Neurological:
-confusion
-restlessness
Integumentary:
- edema
2.1 Assess the need for ambulation aids: bracing, cane, walker,
equipment modification for ADLs. Some aids may require more
energy expenditure for patients who have reduced upper arm
strength (e.g., walking with crutches). Adequate assessment of
energy requirements is indicated.
2.2 Encourage adequate rest periods, especially before meals, other
ADLs, exercise sessions, and ambulation. Rest between activities
provides time for energy conservation and recovery. Heart rate
recovery following activity is greatest at the beginning of a rest
period.
2.3 Provide emotional support while increasing activity. Promote a
positive attitude regarding abilities. atients may be fearful of
overexertion and potential damage to the heart. Appropriate
supervision during early efforts can enhance confidence.
3.1 Maintain adequate ventilation and perfusion, as in the following.
Place patient in semi- to high-Fowler's position.
When fluid overload is an etiology, upright positioning reduces
preload and ventricular filling.
3.2 Maintain optimal fluid balance. For patients with decreased
preload, administer fluid challenge as prescribed, closely monitoring
effects. Volume therapy may be required to maintain adequate
filling pressures and optimize cardiac output.
3.3 Assess respiratory rate, rhythm, and breath sounds. Rapid
shallow respirations are characteristic of reduced cardiac output.
Crackles reflect accumulation of fluid secondary to impaired left
ventricular emptying. They are more evident in the dependent areas
of the lung. Orthopnea is difficulty breathing when supine
4.1 Evaluate weight in relation to nutritional status. In some heart
failure patients, weight may be a poor indicator of fluid volume
Sproule/Douglas/NPII/Student Clinical Prep
28/08/2010
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BSN Program Nursing Practice II
status. Poor nutrition and decreased appetite over time result in a
decrease in weight, which may be accompanied by fluid retention
even though the net weight remains unchanged
4.2 Assess for crackles in lungs, changes in respiratory pattern,
shortness of breath, and orthopnea. These signs are caused by
accumulation of fluid in the lungs.
4.3 Assess for presence of edema by palpating over the tibia, ankles,
feet, and sacrum. Edema occurs when fluid accumulates in the
extravascular spaces. Dependent areas more readily exhibit signs of
edema formation. Edema is graded from trace (indicating barely
perceptible) to 4 (severe edema). Pitting edema is manifested by a
depression that remains after one's finger is pressed over an
edematous area and then removed. Measurement of an extremity
with a measuring tape is another method of following edema.
5.1
5.2
5.3
References: It is anticipated that the required textbook Medical-Surgical Nursing in Canada (Lewis et.al.,
2010) is used for this research. If other sources are used, please provide a brief list here.
Sproule/Douglas/NPII/Student Clinical Prep
28/08/2010
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