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NATALY CALDERA

MRS. BARKER

MAY 11, 2009

LEVEL 3 CASE STUDY

MISSION COMMUNITY HOSPITAL

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

cardiovascular disease. She is of Hispanic descent, non-english speaking, and a strict

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

the urosepsis is cleared and her breathing returns to normal.

DEMOGRAPHICS

PATIENTS INITIALS: M.L


GENDER: FEMALE

AGE : 78 YEARS OLD

ADMISSION HISTORY: DOA 04/08/2009 FROM HOME IN NORTH HOLLYWOOD

MARTIAL STATUS: WIDOWED

RACE: HISPANIC

PAST OCCUPATION: HOMEMAKER

RELIGIOUS AFFILIATION: CATHOLIC

INTERPERSONAL SUPPORT SYSTEM: FOUR SONS AND TWO DAUGHTERS

LIVING ARRANGEMENTS: LIVES WITH DAUGHTERS IN A HOME IN NORTH


HOLLYWOOD.

HOBBIES/RECREATION: COOKING, CLEANING, SPENDING TIME WITH HER


GRAND CHILDREN

SLEEP PATTERN: STATES SHE HAS ABOUT SEVEN HOURS PER NIGHT.

DISCHARGE PLANNING: NOT KNOWN AT THIS TIME

Medical information:
M.L’s primary diagnosis is systemic inflammatory response syndrome

caused by sepsis, caused by improper catheter care.

-Urosepsis is a complication of a urinary tract infection (which caused M.L to become

septic), characterized by bacteria from the urinary tract seeping into the blood stream

causing generalized infection which can lead to septic shock.

Signs and symptoms include dysuria, abdominal [and or flank] pain radiating to back,

cystitis, distention and tenderness of the bladder, tachycardia, hypotension, hematuria.

Systemic symptoms can be fever, rigors, head aches and vomiting.

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.

M.L’s secondary diagnosis is chronic obstructive pulmonary disease. One of

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.

Chronic obstructive pulmonary disease is a progressive inflammatory disease,

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

chronic lung disease which is flattening the diaphragm was noted.

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

tests and b/s.

Nutritional assessment/ Diet therapy


Name of diet: 2000 mg sodium restricted diet.

Special characteristics: sodium restricted/ may use salt substitute.

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

N.p.o orders: not at this time

Ancillary/ Adjunctive therapy


Types of treatments:

• Respiratory therapy twice a day everyday.


• Respiratory to provide breathing treatments albuterol sulfate in nebulizer
1. patient will benefit from these therapies in such ways as excreting all
mucus build up. An improvement of cough is hoped for to improve her
breathing with the C.O.P.D.

Chemistry: hematology: urinalysis


M.L blood labs Reference: guide

H.G.B -18.2 H 13.5-17.0

HCT- 37.0 L 41-50

BUN -24 H 8-23

CREAT- 1.1 H 0.5-0.9

CALCIUM -9.8 H 8.4-9.7

PAO2-121 75-100

PACO2-19 35-45

PH- 7.31 7.35-7.45

HCO3- 15 22-26

URINALYSIS

OCC BLD 3+ NEGATIVE

LEUKO 1+ NEGATIVE

WBC 5-10 0-5

RBC 5-10 0-5

BACTERIA- NONE
Present

FVC –forced vital <60 45-60 moderate 70-75


C.O.P.D norm
capacity

FEV1- forced < 50 % 45-60%= Norm


expiratory volume moderate
C.O.P.D 70-
75%

FVC/FEV1 < 70 Moderate C.O.P.D >75-


80%

Norm

• M.L s hemoglobin elevation is related to her C.O.P.D.

• HCT decrease is related to blood loss.

• BUN and Creatine increase is related to urosepsis and to protein intake at home.

• A.B.Gs indicate acidosis.

URINALYSIS

• The occult blood is form the U.T.I and urosepsis.

• Leuko and wbc count increase because of renal dysfunction

• RBC in crease due to bladder and renal dysfunction, trauma, urosepsis.

• Bacteria in the urine is manifested by U.T.I

• Mucus in the urine indicates renal dysfunction.

MEDICATIONS:
Protonix 40 mg QD PPI which suppresses gastric secretions,
M.L is using this medication to help with
abdominal pain.

Bethanechole 25mg Qd Absence of urinary retention, M.L has


Urinary retention and a urinary tract
infection which has led to sepsis and this
drug is helping the retention and distention.

Dulcolax 10 mg Qd Decrease in constipation. M.L is using this


medication as pre-causative measures due
to the decrease in fluids

Benadryl 25 mg To decrease allergic response. M.L is using


this medication to decrease cough.

Albuterol unit dose Bronchodilator/ helps breath by opening


the alveolar sacs.

Tylenol 500 mg Pain/ fever reducer

Levaquin 500mg For U.T.I

Glucophage 1 gm For Dm

Celebrex 200 mg Pain reliever /antiinflammatory

Atenolol 100 mg For hypertension.

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

orientated x4 with no sensory or motor deficits. No visual impairments, pupil reaction

Perrla, sclera and conjunctiva are white and pink, no abnormal discharge. No hearing

impairments no dentures, oral mucosa is moist and intact, no dysphagia. No cardiac

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.

He.e.n.t- normocephalic eyes ears nose throat all norm.

Neck- supple no distended veins norm.

Lungs- upon auscultation rhonchi crackles and dyspnea.

Heart- tachycardic slight rubbing noise, cardiomegaly.

Breasts- no masses no discharge

Abdomin- obese but also distended related to urinary retention and gastric flatus.

Genitalia - normal female no abnormal discharge.

Extremities- arms warm to touch poor turgor ,>3 cap refill, diminished dorsalis pedis.

NEUROLOGICAL- alert orientated x4 no physical or mental disabilities.

Nursing diagnosis Goals Implementation Evaluation


Fluid volume excess Patient will modify Daily weight Patient displayed
related to renal assessments. appropriate urinary
insufficiency and diet to exclude food output by 2 days.
decrease in urine with salt and Nurse to monitor
output. Manifested potassium which urinary input and Patients was able to
by +1 edema and will worsen edema output. demonstrate
urinary retention. symptoms. While understanding of
admitted will be on Monitor for signs 2000 mg sodium
Secondary to sodium restricted and symptoms of diet.
urosepsis diet but will modify electrolyte
in home setting in 2 imbalances.
weeks.
Teach patient how
Patient will be able to substitute foods at
to reduce fluid to home
non-crisis levels 50-
60% by two days. Give information
pamphlets for
cooking with salt
substitute.

Asses skin,
dependent areas for
edema which are
tissues influenced
by gravity.

1. Accurate intake and output is needed for determining renal function

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.

4. Minimizes boredom of limited choices, and reduces sense of deprivation.

5. An imbalance in electrolytes will give us an insight to help improve and prevent


further fluid volume excess.

Nursing diagnosis Goals Implementations Evaluation


Risk for infection Patient will have Nurse is to use Patients infection
related to infection resolved in aseptic technique resolved in two
continuous use of
invasive catheter three weeks. weeks 3 days.
manifested by Avoid placing urine
hematuria. Patient will bag above insertion Patient is no longer
demonstrate how to site. on foley cath but is
do proper catheter aware of cleaning
care by 9 days. Administer techniques to
antibiotics as prevent further
ordered per M.D infections.

Teach patient proper


catheter care every 2
days until patient
can demonstrate self
care.

1. Reduce the risk contamination because of back flow.

2. Prevents introduction of bacteria, reducing risk of further infection.

3. Help to resolve and prevent further infection.

4. Aseptic technique necessary because gloves can have non-traceable defects.

5. Patient must be taught proper cath care to be able to begin the process of healing
and be able to resolve infection.

Nursing diagnosis Goals Implementation Evaluation


Ineffective airway Patient will Assess patients Patient oxygen
clearance related to maintain patent ability to remove saturation level went
narrowing of airway end day and secretions nurse from 92 to 99 on
bronchioles every shift after assisting as needed. oxygen at 2 liters
manifested by initial. via nasal cannula.
wheezing and Encourage
shortness of breath. Patient wheezing coughing, deep After 4 days of
will decrease in four breathing, and nursing
days expelling of interventions the
secretions. patients wheezing
has decreased
Elevate head of bed dramatically.
have patient lean on
over bed table to
help with breathing.

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.

2. To reduce the viscosity of secretions.

3. Coughing is most effective in upright position, and to be able to expel secretions.

4. assessing is the best way to be able to teach your patient what she doesn’t already
know.

5. Oxygen is vital to all organ function.

Nursing diagnosis Goals Implementations Evaluation


Impaired gas Patient will Administer oxygen Patient displays no
exchange related to demonstrate as ordered. 2 liters signs of cyanosis.
altered oxygen behaviors to via nasal cannula.
delivery improve airway Patient has kept
manifested by clearance and Monitor ABGs respirations
dyspnea, shallow patterns such as report increase or between 18-22 for
breath sounds, pursed lip decrease in PACO2 2+ days.
tachycardia. breathing by weeks AND PAO2
end. 5/18/09
Monitor and report
Patient will be able and changes in
to demonstrate gas vitals 5 above or
exchange by below.
maintaining
respiratory rate Monitor ecg
with in 3 of her changes.
base line which is
22. Elevate head of bed

Patient will Administer


demonstrate medications as
normal depth and indicated.
rate of respirations
by 2 weeks

Patients A.B.Gs
will return to
normal by 6 days

1. Dyspnea, shallow breathing are signs of respiratory distress and require


immediate attention.

2. Tachycardia can increase when patient is unable to get adequate gas exchange.

3. Increase in PAO2 is a sign of respiratory failure.

4. Lack of oxygen will result in cyanosis and needs to be treated immediately.

5. Pursed lip breathing will help with gas exchange in her lungs and will
decrease the shortness of breath.

Nursing diagnosis Goals Implementation Evaluation


Ineffective Patient will Nurse will teach By end of shift
breathing patterns demonstrate patient and will patient able to
related to increase behaviors to provide patient will display a decrease in
production of improve breathing informational shortness of breath
bronchial secretions patterns such as pamphlets for and sustain
manifested by relaxation relaxation respiratory rate
mucus upon techniques by one techniques. between 17-23 when
breathing, shortness week. was 26
of breath. Have patient sit up
Every shift patients to reduce chest Upon discharge
Secondary to shortness of breath pressure. patient was able to
C.O.P.D will decease demonstrate pursed
Monitor oxygen lip breathing and
Patient will sustain saturation relaxation
respiratory rate techniques.
within normal range Administer oxygen
12-20 by 2 days and as ordered Due to nursing
every 3 hours after interventions
that. Suction as needed secretions have
decreased.
Administer
medications as
indicated such as
albuterol sulfate.
Every 4 hrs

1. Promotes better lung expansion which can improve gas exchange.

2. Albuterol will promote airway clearance by helping liquefy secretions for


easier expelling.

3. Proper positioning and elevating helps in drainage of secretions and is


easier to cough up mucus.

4. Accumulation of secretions blocks the airways.

5. To maintain adequate airway patency.

Bibliography
Online references

Nursing care plan guidelines

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

Text book references

Structure and function

Executive publisher Barbara Nelson Cullen

Foundations of nursing fifth edition

Copyright 2006 mosby.inc

Adult health nursing

Executive publisher Tom Wilhelm

Structure and Function of the body

Copyright 2008 mosby.inc

Foundations of nursing
Executive publisher Barbara Nelson Cullen

Foundations of nursing fifth edition

copyright@2006 Mosby.inc

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