NURSING 110 & 111 NURSING CARE PREPARATION

Student Name: Elizabeth Archibald Date of Care: 2/7/17

Unit/Room Number: Med Surg 3-1 Date of Admission: 2-6-17

Age: 73 y/o Ethnic/Cultural Preferences: Caucasian
Gender: female Allergies: Ultram
Eriksons Developmental Level: despair Code Status: DNR/DNI

Primary Diagnosis: COPD with acute hypoxic respiratory failure

Co-morbidities: COPD, CHF, asthma, emphysema, diabetes, lung mass.

Discharge Plan: No plan to discharge now due to declining status.

Integrated Pathophysiology

My patient presented to the E.D. with hypoxia, and SOB without exertion.

Labs were collected to rule out a heart problem, CDiff, influenza, and/or a bleeding disorder.
Radiographs were taken and ProBNP was ran to assess level/possible progression of previously
diagnosed heart disease.

The primary diagnosis = COPD with acute respiratory failure.

Chronic obstructive pulmonary disease(COPD) is a lung disease characterized by long term blockage of
pulmonary gas exchange that interferes with normal breathing and is not curable.
http://www.who.int/respiratory/copd/definition/en/

My patient is a long-term smoker. This is the most probable cause for development of disease. In
addition to patient being a long-term smoker, she also has a lung mass. It is undocumented in the
hospital files if this mass if malignant or benign.

Today, Carol was unable to come from her BIPAP due to inability to adequately retain oxygen.
Biphasic Positive Airway Pressure (BIPAP) is a ventilation system controlled by pressure and allowing
unrestricted breathing PRN during the ventilatory cycle.
https://www.ncbi.nlm.nih.gov/pubmed/8143712

BIPAP hindered patient from eating and drinking freely.

The doctor counseled the patient and family and advised them that patient is now on palliative care.
We will do our best to keep her comfortable for the time that she has left.

Data Collection
Diet (Type): Regular IV (Fluid type, rate, access type): YES, D/Cs
I&O (MD order/Nursing Order/Frequency): BID CBG (Yes/No, frequency): TID
Fall Risk/Safety Precautions (Yes/No): YES Activity (What is ordered): BED REST
Wound Care (Yes/No): NONE Oxygen (Yes/No, Delivery method, how much):
BIPAP
Drains (Yes/No, Type): NONE Last BM: Yesterday
Other Tubes: FOLEY
 Diet (Type): Regular
I&O (MD order/Nursing Order/Frequency): BID
Fall Risk/Safety Precautions (Yes/No): YES
Wound Care (Yes/No): NONE
Drains (Yes/No, Type): NONE
Other Tubes: FOLEY
(Include Subjective & Objective Data)
Integumentary:
Patient states that she is very hot. She has been
out of her covers the entire time she has been
here, with a fan and is still too hot.
Skin is frail, and dry.
Upper extremities are blue: R > L.
There are no wounds present, but unable to
examine coccyx area due to SOB during a resting
state.
Eyes/Ear/Nose/Throat:
Patients eyes are anicteric and symmetrical in
size.
Conjunctiva is pink and moist.
Patient is hard of hearing, and the BIPAP makes it
harder for her to hear.
Unable to examine nose/mouth due to BIPAP.
Cardiac:
Irregular heart rate, AFIB.
All pulses palpate within WNL.
IV (Fluid type, rate, access type): YES, D/Cs
CBG (Yes/No, frequency): TID
Activity (What is ordered): BED REST
Oxygen (Yes/No, Delivery method, how much):
BIPAP
Last BM: Yesterday
ASSESSMENTS
Head and Neck:
No abnormal findings with head and neck.
Patient does not have any masses.
Face is symmetrical, and trachea is midline.
Hair is evenly distributed and not alopecic.
Skin to face, neck, and head are dry.
Thorax/Lungs:
Patient has AFIB, and an irregular heart rate is
present.
Lungs hard very harsh. Patient wheezes during
expiration.
Patient has dyspnea at rest.
There is no sputum production.
Patient is on BIPAP, and cannot maintain O2
SATS on nasal cannula.
Musculoskeletal:
Patient is a fall risk and states that her shoulders
are painful.
Shoulder pain = 6/10. Medication dispensed to
 Cardiac: Musculoskeletal:

Irregular heart rate, AFIB.
All pulses palpate within WNL.
Trace edema to lower extremities.
Patient is a fall risk and states that her shoulders
are painful.
Shoulder pain = 6/10. Medication dispensed to
cover this.

Poor CRT; sluggish = < 3 seconds.

Genitourinary: Gastrointestinal:

Patient has a foley present.
Urine is amber colored and output is slow.
Patient has not been drinking aduate amounts
due to BIPAP.
Patient has not had a BM since yesterday.
Abdominal sounds quiet, but present in all 4
quadrants.
Hard to hear over deep breathing.

Patients abdomen is soft and non-painful.

Patient denies nausea.

Neurological: Other (Include vital signs, weight):

T 97.5 BPM
A&O xs 4 P 94 BPM
Anxious. R 38 BPM
BP 134/77 MMHG
O2 95% on BIPAP
Pain- shoulder = 6/10

Weight= 143 #s

CURRENT MEDICATIONS

Generic Classifi Dose/ Onset/ Expected Adverse Nursing Intervention for

Name cation Route/ Peak outcome reaction this client. (consider
& Trade Rate if (One expected outcome and
Name IV common adverse reaction)
adverse
reaction)
S Furos Loop 20 mg 2-10 Increase fluid Fluid Monitor intake
a emide Diuretic IV minutes output volume and output
m Lasix deficit Monitor for signs/
p symptoms of
l dehydration
e
Loop 40 MG 2-10 Increased Fluid Monitor intake and output.
Furose Diuretic IV Slow minutes fluid output Volume Monitor signs and
mide daily @ Deficit symptoms of dehydration.
(Lasix) 9AM
Antifun 1 Swish Rapid Clear oral Contact Assess Mouth and MM
Generic Classifi Dose/ Onset/ Expected Adverse Nursing Intervention for
Name cation Route/ Peak outcome reaction this client. (consider
& Trade Rate if (One expected outcome and
Name IV common adverse reaction)
adverse
reaction)
S Furos Loop 20 mg 2-10 Increase fluid Fluid Monitor intake
a emide Diuretic IV minutes output volume and output
m Lasix deficit Monitor for signs/
p symptoms of
l dehydration
e
Loop 40 MG 2-10 Increased Fluid Monitor intake and output.
Furose Diuretic IV Slow minutes fluid output Volume Monitor signs and
mide daily @ Deficit symptoms of dehydration.
(Lasix) 9AM
Antifun 1 Swish Rapid Clear oral Contact Assess Mouth and MM
Nystatin gal and (O) fungal Dermititis
(Mycost swallow Unknow infection
atin) PO BID n (P)
Anti- 0.0625 30-120 Increase Fatigue Check radial HR.
Digoxin arrhyth MG PO Mins (O) cardiac Headache Withhold med if HR < 60
(Lanoxin mic daily @ 2-8 H (P) output, and BPM
) Inotropi 9AM decrease HR
cs
Flucona Anti- 150 MG Unknow Eliminate GI Upset Look for rashes
zole fungal PO daily n (O) yeast
(Difluca @ 9AM 2-4 H (P) infection
n)

Blood 81 MG 5-30 Min Anticoagulent GI bleeding Monitor BMs, and sites of

Aspirin thinner PO daily (O) CBG sticks.
E.C at 9AM 1-3H (P)
Tablet
MS 10 MG 1 HR (O) Decrease MS Dizziness Assess Pain levels
Cyclo- Relaxa PO TID 3-8 H (P) Pain Drowsiness
benzapri nt
ne
(Flexeril)
K 25 MG 2-3 H Reduce fluid Dehydratio Monitor I & O
Spirolact Sparing PO daily (O) volume n
one diuretic @ 9AM 2-3 days
(Aldacto (P)
ne)
Fluoroq 500 MG/ Rapid Prevention of GI Upset Assess BMs
Levoflox uinolon D5W @ (O) pneumonia Dizziness Check for rash
acin es 100ML/ End of Insomnia Watch for anaphylaxis.
HR Infusion
Q24H (P)
(11:30A
M)
Lovenox antithro 40 MG Unknow Prevention of GI bleeding Monitor BMs, and sites of
(Enoxap mbotics SQ daily n (O) blood clots CBG sticks.
rin) low @ 9AM 3-5 H(P)
molecul
ar
weight
heparin
s

Pantopr Proton 40 MG 2.5 H Prevents acid GI Upset Assess for nausea, and/or
azole pump- IVP (O) reflux diarrhea.
(Protoni inhibito daily at 1 week
x) r 9AM (P)

Hydro/ Analge 5/325 10-30 Reduces Respiratory Assess RR after onset of

 molecul
ar
weight
heparin
s

Pantopr Proton 40 MG 2.5 H Prevents acid GI Upset Assess for nausea, and/or
azole pump- IVP (O) reflux diarrhea.
(Protoni inhibito daily at 1 week
x) r 9AM (P)

Hydro/ Analge 5/325 10-30 Reduces Respiratory Assess RR after onset of

APAP sic MG PO mins (O) pain depression action.
(Norco PRN 30-60 Monitor O2 sats.
5) Q4h mins (P)

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date Lab Test Patient Values/ Interpretation as related to patients diagnosis
Normal Values Date of care cite reference & pg #
2/7 Sodium 138
135 145 mEq/L
2/7 Potassium 4.2
3.5 5.0 mEq/L
2/7 Chloride 104
97-107 mEq/L
2/7 Co2 25
23-29 mEq/L
2/7 Glucose 146 Patient is diabetic, and stressed related to
75 110 mg/dL inability to breathe.
2/7 BUN 21
8-21 mg/dL
2/7 Creatinine 0.66
0.5 1.2 mg/dL
2/7 Uric Acid
Plasma
4.4-7.6 mg/dL
2/7 Calcium 8.9
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
2/7 WBC 8.9
4.5 11.0
2/7 RBC 4.45
male: 4.7-5.14 x
10
 Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
2/7 WBC 8.9
4.5 11.0
2/7 RBC 4.45
male: 4.7-5.14 x
10
female: 4.2-4.87
x 10
2/7 HGB 14.4
male: 12.6-17.4
g/dL
female:
11.7-16.1 g/dL
2/7 HCT 42.7
male: 43-49%
female: 38-44%
2/7 MCV 96.1
85-95 fL
2/7 MCH 32.4
28 32 Pg
2/7 MCHC 33.7
33-35 g/dL
2/7 RDW 14.1
11.6-14.8%
2/7 Platelet 171
150-450

DIAGNOSTIC TESTING

Date UA Interpretation as related to

Normal
Results Pathophysiology cite reference &
Range
pg #
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood

Date Other Interpretation as related to

(PT, PTT, INR, Normal Pathophysiology cite reference &
Results
ABGs, Cultures, Range pg #
etc)
2/7 Manual Diff NEG NEG
2/7 Troponin 0-0.05 0.11 ng/mL This has gone down since original
# of 0.2 (2/6). This is monitored to
see if it goes up indicating heart
problems.
2/7 CK-MB 0-6 7.3 ng/mL Elevated R/T use of systemic
steroid
https://respiratory-
research.biomedcentral.com/
articles/10.1186/1465-9921-13-12
2/7 CPK 30-223 95 u/L
2/6 Lactate 0.5-2.2 1.10 mmol/L
2/6 Flu A&B NEG NEG
2/6 CGH-PTT 24.5-32.8 25.5 SEC
 etc)
2/7 Manual Diff NEG NEG
2/7 Troponin 0-0.05 0.11 ng/mL This has gone down since original
# of 0.2 (2/6). This is monitored to
see if it goes up indicating heart
problems.
2/7 CK-MB 0-6 7.3 ng/mL Elevated R/T use of systemic
steroid
https://respiratory-
research.biomedcentral.com/
articles/10.1186/1465-9921-13-12
2/7 CPK 30-223 95 u/L
2/6 Lactate 0.5-2.2 1.10 mmol/L
2/6 Flu A&B NEG NEG
2/6 CGH-PTT 24.5-32.8 25.5 SEC
2/6 PH of O2 7.32-7.43 7.29
Date Interpretation as related to
Radiology Results Pathophysiology cite reference &
pg #
2/6 X-Rays Cardiomegaly with slight Patient has an enlarged heart R/T
vascular prominence heart failure. Fluid builds up, and
centrally. heart hypertrophies secondary to
increased work load.
Scans
EKG-12 lead
Telemetry

DAR NURSING PROGRESS NOTES

2/7/17 8:00AM
Priority Diagnosis: Diabetes
D: Patient has a history of diabetes. CBG ordered for BID.
A: Informed patient of procedure, and expected outcome.
Patients right finger massaged and alcohol swabbed. Pricked finger with lancet, and produced sufficient
amount of blood.
Described sliding scale to patient.
R: CBG = 135 (>/= to 150 is bottom end of sliding scale). Insulin withheld.
S: Liz, SN

2/7/17
Priority Diagnosis: Pain
D: 10 AM patient C/O shoulder pain
A: Patient reports pain 5/10. Cindy (charge nurse) notified.
R: Charge nurse and student nurse administer patient Norco5
S: Liz, SN
2/7/17 10:30 AM
Priority Diagnosis: COPD with acute respiratory failure
D: Patient is a long-term smoker. Left arm is intact, and non-painful.
A: Nicotine patch utilized. Applied nicotine patch to intact, clean, dry skin out of the way of any tubes/IVC.
Initialed, dated, and timed patch for future nurse info.
R: Patient states that nicotine patch made her feel less anxious.
S: Liz, SN

2/7/17
Priority Diagnosis: Palliative Care
D: Patient is in last stages. Steps are being taken to keep patient comfortable.
A: Bed bad given to patient, and lotion applied. Modeling noted to right inferior arm.
R: Patient appeared more comfortable.
S: Liz, SN

PATIENT CARE PLAN

 Patient Information (Include data to support selected nursing diagnostic statement):

See Above

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).
Problem #1 Anxiety R/T terminal illness AEB shortness or breath.
Desired Outcome: Patient will be at peace in her last days on earth.
Nursing Interventions Client Response to Intervention
1. Check on patient every hour to see if patient 1. Patient likes the attention.
needs anything.

2. Assess pain levels and control pain PRN with 2. Morphine and Norco control pain well.
morphine, and Norco.

3. Provide comfort care measures to patient such 3. Patient seemed more comfortable after these
as bed bath and lotion application. procedures.

4. Keep patient cool with her fan, and wetted 4. Patient seemed to cool down a bit.
washcloths.
Patient gets very hot.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):

Problem #2 Risk for impaired skin integrity R/T immobility AEB SOB without exertion.
Desired Outcome:
Nursing Interventions Client Response to Intervention
1. Turn patient every 3 hours to avoid skin 1. Moving patient is hard because it takes a lot of
breakdown. oxygen out of her.

2. Elevate feet to encourage blood flow. 2. Patient likes this if her feet are out from under
the blankets.
3. Keep skin moisturized, and free of wrinkled 3. Patient states that her distal legs are painful.
clothing/bedding.

4. Control CBG with insulin PRN, and monitor O2 4. Patient does not mind her CBG being taken.
sats. O2 sats drop if patient is taken off of BIPAP.
Both will help reduce risk of ulcerations.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):