MRS. BARKER
INTRODUCTION
M.L is a 78 year old female, with no known allergies. She was admitted on April
8, 2009 with chief complaint of altered mental status, a fever of 102.9 and a ground level
fall. M.L has diagnosis of urosepsis and C.O.P.D with history of DM, HTN and
catholic. She attends church on a regular basis every Friday and Sundays. M.L’s religious
beliefs did not affect her care and it did not interfere with the nursing skills provided to
her. She can answer to simple commands of the staff but cannot hold a full conversation
unless in Spanish or with the help of a translator. Some practices may cause confusion
because of her inability to speak English. There is not always a translator around for her
to understand what the staff is saying or what the doctors are trying to tell her. But she
does her best and so does the staff to accommodate her. M.L is a widow who has chosen
not to re-marry. M.L was transferred to mission community via ambulance from her
home in North Hollywood. M.L has four sons and two daughters, whom she lives with
and who are her main support systems. She stated to me that Hispanics believe that in a
family everyone takes care of everyone and leave none alone. M.L enjoys watching her
grandchildren and cooking for the family, in her spare time she really enjoys coming up
with different ways to cook all different kinds of foods. She stated “everyone needs
something new in their life”. About all of her life she has been a house wife until her
husband passed which was about five years ago. Speaking to her it was noticed that she
has very good mental status with no difficulty remembering anything. M.L has urosepsis
which includes problems with urinating and a harsh amount of pain that is always
radiating from her abdomen to her back. These signs and symptoms make it hard for M.L
function on a day to day basis. M.L has C.O.P.D which is a lung disease that makes it
hard to breathe. It is caused by the damage to the lungs over many years, usually from
smoking. M.L was a smoker for over 20 years which may have been the cause of this
disease. Symptoms may include a long-lasting (chronic) cough mucus that comes up
when you cough, and shortness of breath that gets worse when u exercise. M.L has a very
hoarse cough that is continuous and has been improving with the help of breathing
treatments daily. According to Erickson’s theory, M.L is in ego integrity versus despair.
She is a very strong woman and states she has lives her life to the fullest and
accomplished all she can. Plans for discharge are unknown as of now until infection of
DEMOGRAPHICS
RACE: HISPANIC
SLEEP PATTERN: STATES SHE HAS ABOUT SEVEN HOURS PER NIGHT.
Medical information:
M.L’s primary diagnosis is systemic inflammatory response syndrome
septic), characterized by bacteria from the urinary tract seeping into the blood stream
Signs and symptoms include dysuria, abdominal [and or flank] pain radiating to back,
The urinary tract, from the kidneys to the urethra, is normally sterile and resistant to
bacterial infection even thought there is frequent contamination with colonic bacteria.
Urethral sphincters, mucosal barriers urine acidity, emptying of the bladder when you
feel like going are part of the mechanisms that maintain the urinary tract sterile. Most
urinary tract infections are caused by e.coli which is a bacterium found only in the
colon/feces.
the most common signs of C.O.P.D is shortness of breath which M.L was exhibiting upon
arrival to the emergency room. Other signs and symptoms include persistent cough,
sputum, and major mucus production. The patient might experience wheezing, chest
tightness and tiredness. Patients with severe C.O.P.D may develop respiratory failure.
which affects the connective airways, and its vasculature. Obstructive lung disease
usually follows with cystic fibrosis, alveolar collapse, and asthma. The pathophysiologic
process of C.O.P.D consists of increased resistance to airflow, loss of lung elasticity and
decreased expiratory rate. The alveolar walls of the lungs frequently break due to the
increase in resistance of air flows. If respiratory failure occurs the patient is deprived of
oxygen and the patient’s skin starts to turn cyanotic/bluish due to the deprivation of
oxygen to tissues.
M.L was a smoker, casual drinker for 20 plus years. M.L came in with shortness of breath
stating “I can’t get enough air in”, I feel like a fish out of water”. Wheezing and crackles
were auscultated. A chest x-ray ordered, found a slight enlargement of the heart and
Diagnostic tests for M.L disease process:Urine culture and sensitivity, voiding
cystogram, spirometer breathing test, C.T, chest x-rays, A.B.G, pulmonary functioning
Reason patient is placed on this diet: she is placed on this diet because she needs
to limit her salt intake to prevent further fluid overload from her C.O.P.D, and urosepsis.
Patients compliance to diet and feelings towards diet: M.L has negative
feedback of this diet she tries to enjoy it as much as possible. Although one concern she
does have is that the salt substitute, she stated “it does not add as much of flavor as
regular salt”. She says she tries to avoid high sweet products to control her diabetes. At
times she will eat about 80 % of her breakfast, lunch and dinner. There are times that she
will only eat about 50% of her meals she states its because she is tired of eating tasteless
food” about 2x week.
Nutritional support: NA
PAO2-121 75-100
PACO2-19 35-45
HCO3- 15 22-26
URINALYSIS
LEUKO 1+ NEGATIVE
BACTERIA- NONE
Present
Norm
• BUN and Creatine increase is related to urosepsis and to protein intake at home.
URINALYSIS
MEDICATIONS:
Protonix 40 mg QD PPI which suppresses gastric secretions,
M.L is using this medication to help with
abdominal pain.
Glucophage 1 gm For Dm
B/p 140/69 pulse 102, resp. 24, temp 102.9 pain 3/10
M.L is a 78 year old patient with septic syndrome, cadiomegaly, C.O.P.D, acute febrile
illness edema in lower extremities +1. M.L is in the developmental stage of ego integrity
v.s despair. M.L complains of 3/10 pain on her right side she stated to me that it was a
“throbbing” feeling and keeps grasping her right flank. On a 2000 mg sodium restricted
diet. M.L’s skin is dry and intact, warm to touch with poor turgor no impairments. Alert
Perrla, sclera and conjunctiva are white and pink, no abnormal discharge. No hearing
murmurs but has poor capillary refill and pedal pulses are not palpable due to edema.
Upon admission oxygen saturation was 83 then it spiked to 92 on room air M.D ordered
oxygen two liters via nasal cannula. Complains of shortness of breath, breath sounds are
labored has wheezing rhonchi. Edema in right arm and legs +1, her abdomen is distended
because of gastric upset/ flatus and urinary retention. Bowel sounds present in all four
quadrants no abdominal tenderness. M.L last bowel movement at 1530 loose related to
medication. Is completely continent but has a foley catheter in for continuous bladder
irrigation. Ambulatory needs assistance to rest room to have a bowel movement because
of foley catheter. M.L can perform active range of motion on all extremities and has no
physical or congenital deformities. As of now in her room with no acute distress, with
one of her daughters, with bed In lowest position left side rail down call bell present no
restraints.
M.L’s review of systems indicates hypertension and chronic pulmonary obstructive
disease.
Abdomin- obese but also distended related to urinary retention and gastric flatus.
Extremities- arms warm to touch poor turgor ,>3 cap refill, diminished dorsalis pedis.
Asses skin,
dependent areas for
edema which are
tissues influenced
by gravity.
2. Daily weights assessments are the best was to asses fluid volume status
3. Edema occurs primarily in dependent tissues, patient can gain 10lbs before
pitting edema can be detected.
5. Patient must be taught proper cath care to be able to begin the process of healing
and be able to resolve infection.
Monitor oxygen
saturation and
tubing patency –
make sure its on the
patient correctly and
is always at 2 liters.
1. Elevation of the bed facilitates breathing and opens up airway by the use of
gravity.
4. assessing is the best way to be able to teach your patient what she doesn’t already
know.
Patients A.B.Gs
will return to
normal by 6 days
2. Tachycardia can increase when patient is unable to get adequate gas exchange.
5. Pursed lip breathing will help with gas exchange in her lungs and will
decrease the shortness of breath.
Bibliography
Online references
http://home.hiwaay.net/-theholt1/nurs1100/careplan.htm
rncentral
COPD
http://www.ncbi.nlm.nin.gov/pobmed/785706
http://www.healthsystem.virginia.edu/uuahealth/adult_
Gas exchange
http://www.stemnet.nf.ca/~dpower/resp/exchange.htm
Foundations of nursing
Executive publisher Barbara Nelson Cullen
copyright@2006 Mosby.inc