Question

A 68-year-old Filipina with history of dyspnea and lethargy.

TRIAGE:

▪ Temperature: 37.2 Celsius

▪ Blood pressure: 200/100mmhg

▪ Heart rate: 70 beats per minute.

▪ Respiratory rate: 36 per minute.

▪ O2 Saturation: 92%

ASSESSMENT:

▪ Dyspnea

▪ Lungs wheezing

▪ Lethargic

▪ Pale

▪ Bilateral pedal

edema

▪ Disoriented to time,

place and people.

ASSESSMENT:

▪ DM and Hypertensive for more than

10 years.

▪ Hyperglycemia

▪ Ultrasound: Chronic renal

parenchymal disease.

▪ CXR: Suspected basal pneumonia with

pulmonary congestion.

LABORATORY RESULT:

▪ ABG (with O2 5L/min.)

- ph 7.173

- PCO2 25.9 mmhg

- PO@ 81.7 mmhg

- HCO3 – 12.8mmol/L

▪ Potassium: 6.0mmol/L

▪ Urea : 64.9mmol/L

▪ Creatinine: 924 umol/L

Guide Questions :

1. What will be your focused physical priority assessment

before you start your care ?

2. Make an interpretation/Inferences in every laboratory

results of the client.

3. Identify at least 5 priority problems and make a Nursing care plan.

4. Analyze the possible medical and surgical management for the client.

Answer 1

Focused physical assessment:

Respiratory system: the signs of severity:  Behaviour of the patient: The patient is lethargic.

Tachypnoea, Increased Blood Pressure,

History: Onset + duration of symptoms cough / shortness of Breath.

Inspection/Observation:

Observe the overall appearance: The client is disoriented, lethargic

• Colour(centrally and peripherally): pink, flushed, pale, mottled, cyanosed , clubbing
• Respiratory rate, rhythm and depth (shallow, normal or deep): 36 bpm
• Respiratory effort (Work of Breathing -WOB): mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath
• Use of accessory muscles (UOAM): intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring, tracheal tug.
• Symmetry and shape of chest
• Tracheal position
• Audible sounds: vocalisation, wheeze, stridor, grunt, cough - productive/paroxysmal
• Monitor for oxygen saturation: 92%

Auscultation

• Listen for absence /equality of breath sounds
• Auscultate lung fields for bilateral adventitious noises e.g.: wheeze, crackles, stridor etc

Palpation

• Bilateral symmetry of chest expansion
• Skin condition – temperature, turgor and moisture
• capillary refill (central/peripheral)
• Fremitus (tactile)
• Subcutaneous emphysema.

Cardiovascular :

Inspection:

• Examine circulatory status and hydration status of upper and lower extremities:
• Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed, clubbing
• Capillary Refill Time (CRT): brisk (< 2 sec) or sluggish
• Presence of oedema (central and/or peripheral): b/l pedal edema seen
• Hydration status: Skin turgor, oral mucosa

Palpation:

• Palpate central and peripheral pulses for rate, rhythm and volume: 70 bpm
• Skin condition – temperature(peripheral and central), turgor and diaphoresis

Auscultation:

• Auscultate the apical pulse
• Compare peripheral pulse and apical pulse for consistency (the rate and rhythm should be similar).
• Auscultate the chest for heart sounds and murmurs.

Renal

An assessment of the renal system includes all aspects of urinary elimination

• Urinary pattern, incontinence, frequency, urgency, dysuria
• Hydration status including fluid balance, BP which is 200/100 mm Hg and weight.
• Skin condition: temperature, turgor and moisture
• Urine output
• Urinalysis (pH, ketones, protein, blood, leukocytes, specific gravity)
• Review blood chemistry results, urea, creatinine, electrolytes, albumin and haemoglobin

2. Interpretation of lab results:

ABG analysis that shows

ph 7.173 - When carbon dioxide builds up in the blood, it dissolves and creates an acid. If the blood acid level is out of balance, it can mean the body isn't able to get rid carbon dioxide efficiently. This may happen because lungs aren't working well or kidneys can't get rid of the acid. A normal result is between 7.35 and 7.45.

- PCO2 25.9 mmhg: Normal values for PaCO2 are usually 35-45 mmHg. The PaCO2 is directly measured and is used to estimate CO2 exchange. An increase in ventilation rate or volume decreases CO2 and shifts the above equation to the left, decreasing the concentration of hydrogen ions, and alkalemia. Compensation is achieved by decreased renal bicarbonate absorption.

- PO@ 81.7 mmhg: The principal clinical value of measuring pO₂(a) and sO₂(a) is to detect hypoxemia, which can be defined as a reduced amount of oxygen in blood. Hypoxemia is diagnosed if pO₂(a) and/or sO₂(a) are below the lower limit of their respective reference range.

• Normal PaO2 values = 80-100 mmHg

- HCO3 – 12.8mmol/L: Respiratory disorders are due to hypercarbia or hypocarbia. A shift in the following equation leads to an increase or decrease in the number of hydrogen ions, changing the pH. H2O + CO2 < -> H+CO+ < -> [HCO3-] + H+. Metabolic disorders are related to decreased losses, or increased ingestions or production of acids or bases. Metabolic disorders are reflected by a change in [HCO3-]

▪ Potassium: 6.0mmol/L: Acute respiratory acidosis causes marked increases in cerebral blood flow. Acute elevation of the Pco2 level to more than 60 mm Hg causes confusion and headache.

▪ Urea : 64.9mmol/L: A blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that comes from the waste product urea

▪ Creatinine: 924 umol/L: A BUN test may be done with a blood creatinine test. The level of creatinine in the blood also tells how well the kidneys are working—a high creatinine level may mean the kidneys are not working properly.

Nursing Diagnosis:

1. Ineffective Airway Clearance related to Decreased energy, fatigue secondary to pneumonia.

Assessment:

• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea

Below are the common expected outcomes for ineffective airway clearance secondary to pneumonia:

• Patient will identify/demonstrate behaviors to achieve airway clearance.
• Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions.

Interventions:

Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles.

Assess cough effectiveness and productivity

Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.

Elevate head of bed, change position frequently.

Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage her to do so often.

Administer medications as per advice

Monitor serial chest x-rays, ABGs, pulse oximetry readings.

2. Impaired Gas Exchange related to Alveolar-capillary membrane changes.

Assessment:

• Dyspnea, Tachypnea
• Pale, dusky, skin color
• Cyanosis
• Disorientation

Common expected outcomes for the nursing diagnosis impaired gas exchange secondary to pneumonia:

• Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
• Patient will maintain optimal gas exchange.
• Patient will participate in actions to maximize oxygenation.

Interventions:

Assess respirations: note quality, rate, rhythm, depth, use of accessory muscles, ease, and position assumed for easy breathing.

Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).

Assess mental status, restlessness, and changes in level of consciousness.

Maintain bedrest by planning activity and rest periods to minimize energy use. Encourage use of relaxation techniques and diversional activities

Elevate head and encourage frequent position changes, deep breathing, and effective coughing.

Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.

3. Ineffective Breathing Pattern related to Alteration of patient’s O2/CO2 ratio

Assessment:

• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea
• Cough, effective or ineffective; with/without sputum production
• Cyanosis
• Decreased breath sounds over affected lung areas
• Infiltrates seen on chest x-ray film
• Reduced vital capacity

Outcome:

Common goals and outcomes for ineffective breathing pattern:

• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
• Patient’s respiratory rate remains within established limits.

Interventions:

Assess and record respiratory rate and depth at least every 4 hours.

Assess ABG levels, according to facility policy.

Encourage sustained deep breaths by:

• Using demonstration: highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation
• Utilizing incentive spirometer
• Requiring the patient to yawn

Encourage diaphragmatic breathing for patients with chronic disease.

Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.

4 Ineffective tissue perfusion related to  loss of kidney excretory functions

Assessment:

• Increase in Lab results (BUN, Creatinine, Uric Acid Level)
• Edema
• Pulmonary Congestion
• Hypertension

Outcome:

Planning

• Patient will demonstrate participation in her recommended treatment program.
• Patient will demonstrate behavior/lifestyle changes to prevent complications

Interventions:

Monitor and record vital signs.

Note characteristic of urine: measure urine specific gravity.

Note mentation status and review lab result such as BUN and creatinine levels.

Measure urine output on a regular schedule and weigh daily.

Provide diet restriction as indicated, while providing adequate calories.

Administer medication as ordered.

5. Disturbed Thought Process related to accumulation of toxins (e.g., urea, ammonia), metabolic acidosis, hypoxia; electrolyte imbalances.

Assessment:

• Disorientation to person, place, time
• Changes in behavior: irritability, withdrawal, depression, psychosis

Outcome:

• Regain/maintain optimal level of mentation.
• Identify ways to compensate for cognitive impairment/memory deficits.

Interventions:

Assess extent of impairment in thinking ability, memory, and orientation. Note attention span.

Provide SO with information about patient’s status.

Reorient to surroundings, person, and so forth. Provide calendars, clocks, outside window.

Monitor laboratory studies such as BUN and Cr, serum electrolytes, glucose level, and ABGs (Po₂, pH).

Provide supplemental O₂ as indicated.

4: Medical and surgical management of client:

Antibiotics. These medicines are used to treat bacterial pneumonia. It may take time to identify the type of bacteria causing pneumonia and to choose the best antibiotic to treat it.

Cough medicine. This medicine may be used to calm cough so that the client can rest.

Respiratory therapy, which involves delivering specific medications directly into the lungs.

Oxygen therapy to maintain oxygen levels in the bloodstream (received through a nasal tube, face mask, or ventilator, depending on severity)

High blood pressure medications. People with kidney disease may experience worsening high blood pressure. Doctor may recommend medications to lower blood pressure — commonly angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers — and to preserve kidney function.

Medications to lower cholesterol levels.: People with chronic kidney disease often experience high levels of bad cholesterol, which can increase the risk of heart disease.

Medications to relieve swelling.:

chronic kidney disease may retain fluids. This can lead to swelling in the legs, as well as high blood pressure. Medications called diuretics can help maintain the balance of fluids

A lower protein diet to minimize waste products in the blood:To reduce the amount of work the kidneys must do, doctor may recommend eating less protein.

In case of serverity may require Dialysis. to remove toic substances from blood

It can be hemodialysis or peritoneal dialysis

Last intervention can be renal transplantation