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PMH: aortic stenosis, CAD, morbid obesity,

paroxysmal atrial fibrillation, respiratory


Congestive Heart Failure
failure with hypoxia and hypercania, COPD,
COPD CHF
Former smoker (1.5 packs/day 40 years)
Ineffective gas Ventricular dysfunction
exchange as a result prevents normal blood flow
of COPD cause and causes the blood to Bumetanide: 2mg IV
hypoxemia and back up into the atrium and injection; inhibits Na+ & Cl
Albuterol-ipratropium: 2.5mg- pulmonary veins, resulting reabsorption in ascending loop
0.5mg/3ml nebulizer; hypercapnia
in pulmonary edema of Henle (diuretic)
bronchodilator that widens and affecting ventilation
relaxes airway in lungs and perfusion (E.M., 79-year old)
Acute on
chronic
respiratory
Pertinent Physical Examination findings: failure Propofol: 0.599-
Patient was restrained bilaterally with Respiratory failure is the result of inadequate 5.99mg/min IV infusion;
wrist restraints. He was sedated and intubated and intake of oxygen or inadequate removal of MOA: sedate intubated
also had a NG tube. Patient had crackles in carbon dioxide. Respiratory failure is a disease ICU patients
the base of lungs bilaterally. He had but a symptom of underlying pathologic
300ml of urine output in the first 3 hours of the shift
condition affecting lung function. In the case of
this patient, his heart failure was the cause of his
respiratory failure

Priority Nursing Diagnosis (3 parts) (Lewis, pg. 1654-1655)


Measurable outcome w/ timeframe:
Psychosocial / Spiritual issues
Impaired gas exchange related to pulmonary edema as
evidenced by crackles in base of lungs and abnormal and discharge needs
ABGs It will be important to discuss
Outcome: Patient will maintain adequate gas exchange with the patient why he is
as evidenced by clear bilaterally lung sounds and normal Patient needs to be taught the noncompliant with his
range ABGs by end of shift.
importance of medication medications

Nursing interventions you used with rationales: compliance and also the
1) Change the patients position every 2 hours (rationale: importance of maintaining Recent laboratory/diagnostic tests results with significance
repositioning facilitates secretion movement and active instead of sitting in a (i.e. why are they high/low?)
drainage.) chair all day. Chest x-ray was positive for pulmonary edema with left
2) Maintain oxygen administration as ordered (rationale: pleural effusion indicating why he was having respiratory
failure
supplemental oxygen is required to maintain PaO2 at an CO2 level on 11-16-16 was 47.5 which is high because his
adequate level.) lungs are not able to release because of the fluid
3) Administer medications as prescribed (rationale: the ABGs: pH-7.576, paCO2-47.5, HCO3-44.2, pO2-95; indicates
administration of diuretics removes fluid from lungs for metabolic alkalosis, which could be the result of his 1
better gas exchange.) electrolyte imbalances due to the diuretics
Evaluation: Patient outcome was not met as he still had
some crackles in his lungs and his ABGs were not in
normal range.
Guide for Reflection
Guide for Reflection Using Tanners (2006) Clinical Judgment Model

Program Thread: Servant Leadership Global Health

My last week in clinical was interesting, but not because anything critical or outrageous happened. My patient was
admitted to the ICU because of respiratory failure related to his congestive heart failure. The part that was interesting to me
was the fact that he had been in and out of the hospital for the same thing multiple times, and it was due to his
noncompliance with his medications. I couldnt understand why someone would continually stop taking his medications
when he knew the result would end up being admitted to the hospital once again with breathing issues. It just seems like
after the first experience that would be enough for anyone to tell himself or herself how important it is to stay compliant
with their medications. I do realize that it is unfair of me to judge my patient because there could be a psychological reason
why he doesnt want to take his medications and if someone could get at the root cause of it, maybe they can help him to a
better quality of life. The entire experience was eye opening because for the first time in clinical, there was no real goal for
the patients recovery. Of course the focus was to remove the fluid so he could breathe without the use of a ventilator, but
after that, there isnt much the doctors can do because his diagnosis was the direct result of his heart failure that was
exacerbated because of his non compliance with medications. In an instance like this, I believe that all we can do is
continue to stress to the patient the importance of taking his medications and hope that he understands how vital it is to his
quality of life.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment

Model. Journal of Nursing Education, 46(11), p. 513-516.

Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. Philadelphia,

PA: Elsevier Inc.

Lewis, S.L., Dirksen, S. R., Heitkemper, M.M., Bucher, L. (2014). Medical-surgical nursing: Assessment and

management of clinical problems. St. Louis, MO: Elsevier Mosley Inc.

List two goals for the next practicum experience:


1. Since this was my last practicum for the semester, one of my goals is to have really good experiences next
semester.
2. My second goal is to well on all my finals for this semester.