NURSING 111 CARE PREPARATION

Student Name: Quinlyn Deming

Date of Care: 2/25/16

Unit/Room Number: 239 REU

Age: 93
Gender: Male
Eriksons Developmental Level: Ego
integrity vs. despair

Date of Admission: 2/23/16

Ethnic/Cultural Preferences: White.
Allergies: Penecillins, lyrica, Cipro
Code Status: DNR

Primary Diagnosis:
Acute Respiratory Failure

Co-morbidities:
CHF, Cataracts, hypertension, iron deficiency anemia, spondylosis, aortic valve
replacement, kyphosis, history of shingles, prostate cancer, CVA.

Discharge Plan (add day of clinical):

Patient is nearing end of life. The focus of the family and health care team is on comfort
care at this point.

Integrated Pathophysiology (what is going on with your patient at the cellular level for the health
condition, no more than three pages in length, including reference page)

Patient was seen in the emergency room on the twenty third of February for a chief
complaint of shortness of breath. His wife was with him and stated that over the past few
weeks he has been experiencing increased weakness and shortness of breath. In the
doctors note it says he is normally ambulatory on his own but when it got to the point
that he couldnt get out of his chair his wife decided to bring him to the emergency
room. The main diagnoses for the patient is acute respiratory failure, but he is also
suffering from congestive heart failure which exacerbated the respiratory failure. The
patient has been put on Lasix to help him offload some of his fluid. He is also on 2 liters
of oxygen through a nasal cannula and on BiPAP therapy.

In order for the lungs to function properly there must be a balance between
ventilation and perfusion for adequate gas exchange to take place. When there is an
imbalance between the two gas exchange is impaired and respiratory failure can be the
end result. There are two categories to classify respiratory failure; ventilatory failure and
oxygenation failure. There can also be a combination of the two together. According to
Ignatavicius and Workman, whatever the underlying problem, the patent in acute
respiratory failure is always hypoxemic. (Ignatavicius and Workman, 2016 Pg.611).
When a patient is experiencing ventilatory failure there is an impairment with oxygen
intake and blood flow which leads to a ventilation-perfusion mismatch where perfusion is
normal but the movement of air is inadequate. During oxygenation failure pulmonary
blood is not oxygenated adequately but the movement of air is not impaired.
There are a few factors that can lead to oxygenation failure. One factor is
congestive heart failure, which my patient has. Another way oxygenation failure can
occur is when the patient has abnormal hemoglobin that fails to bind to oxygen. My
patient also has iron deficiency anemia so this could be playing a role in his respiratory
failure (Ignatavicius and Workman, 2016).
After reading the doctors note and what they had discussed with the patients
family, I learned that they are focusing on providing palliative care at this point. My care
of the patient tomorrow will be focused on this as well. From the sounds of what this
patient is experiencing and the doctors note I am under the impression that this patient
is nearing the end of life. My priority tomorrow will be providing a calming environment,
assisting the patient with breathing exercises and doing whatever I can to make him feel
more comfortable.

Ignatavicius, D. D., & Workman, M. L. (2016). Medical-surgical nursing: Patient-centered

collaborative care (8th ed.). St. Louis, MO: Elsevier. 611-612.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular, 2 GM sodium
IV (Fluid type, rate, access type):

I&O (MD order/Nursing Order/Frequency): Nursing

ordered at meal time.
Fall Risk/Safety Precautions (Yes/No): yes,
follow safety protocol.
Wound Care (Yes/No): Yes, second toe R foot.
Bottom of fourth toe R foot.
Drains (Yes/No, Type): No.

Furosemide 2
ml/8 hours IV push. Will assess site
tomorrow.
CBG (Yes/No, frequency): No.
Activity (What is ordered): 1-2 person
ambulation assistance.
Oxygen (Yes/No, Delivery method, how much): NC
2 LPM to keep O2 sats > 93% or
Last BM: Nothing in computer, will assess
tomorrow. Pt stated he hasnt had one in
several days.

Other Tubes: No.

ASSESSMENTS
(Include Subjective & Objective Data)

Integumentary:
Skin is uniform in color and warm to touch
throughout entire body. Hair is black/grey
and balding. Nails are clean, intact and
smooth. Pt does have bluish discoloration
on both hands and bruises scattered
throughout upper extremities. Healed scar
on his chest approximately 6 in in length.
Stage 2 pressure ulcer on coccyx, open
wound, approximately in length, nonblanchable. Open ulcer on left calf,
approximately 2 in length and 1 wide,
non blanchable. Both ulcers are at skin
level as of now, not deep wounds. Bilateral
calf, ankle and pedal edema, pitting + 2.
Feet red, dry and flakey. In between toes is
dry and flakey.

Head and Neck:

Head is slightly cocked to the left, nontender to touch, no masses or lesions
present. Facial features are symmetrical.
Neck is also slightly cocked to the left, nontender, w/ no masses present. Neck has full
ROM.

Ear/Nose/Throat/eyes:
Oral cavity was scattered w/ food
remnants. Very dry and white discoloration

Thorax/Lungs:
Patient is on continuous BIPAP therapy.
Chest expansion is symmetrical, no

on left side of tongue. Lips were dry. Pt

could swallow meds but it was difficult.
Nose is midline, symmetrical, no discharge
present and no nasal flaring.
Eyes are blue, pupils are pinpoint, sluggish
to light, sclera is cloudy in appearance, and
tinted yellow. Pt can make eye contact.
Cant keep eyes open for more than
approximately 5 seconds. History of
cataracts in both eyes.

difficulty breathing, no use of accessory

muscles, RR rate is 20, rhythm is regular.
Upper right lobe, middle right lobe and
lower right lobe were diminished w/ fine
crackles heard on inspiration anteriorly.
Posterior upper right lobe middle right lobe
and lower right lobe were diminished w/
fine crackles on inspiration. Could not
assess posterior left lobes due to pts
position and inability to sit up. While eating
pt has increased cough after every bite or
drink of liquid, also experiences more SOB
while eating.

Ears have wax present, hearing aides in

both ears, pt can hear well enough of to
respond and follow directions. Ears are
pliable and non-tender to touch.

Cardiac:
Capillary refill is less than 3 seconds,
edema in hands, calves, ankles and feet.
Hands have non pitting edema, and calves,
ankles and feet are pitting +2. Pulse is
bradycardic at 50 b/m. BP is hypotensive at
93/45. Auscultation showed bradycardia,
but no abnormal rhythm present. Radial
pulses are equal bilaterally and strong.
Pedal pulses were not palpable by touch,
but present upon use w/ Doppler and equal
bilaterally.

Musculoskeletal:
Pt is non ambulatory. Is able to help move
himself around in bed w/ assistance but not
alone. Equal hand grasps. Does have
kyphosis. Can perform ankle pumps against
gravity but not against force. Can lift up
legs and bend at the knees w/out difficulty.

Genitourinary:
Area has foul order, Scrotum is swollen and
red, discharge present white/brown in color
coming from the corona area. Grey hair
present.

Gastrointestinal:
Pt stated has not had BM in several days.
Normoactive bowel tones present in all four
quadrants. Abdomen is not distended, nontender, and shows no lumps or masses.

Neurological:
Patient is alert when you speak to him,
otherwise he lays with his eyes closed
resting. Will follow instructions well and is
cooperative. Opens eyes when asked, but
cant keep them open for a long time.
Speech is intact, takes a while for him to
gather thought, but they do eventually
come out, slightly slurred speech. BIPAP
machine makes it difficult to understand,
but he is clear and logical.

Other (Include vital signs, weight):

BP= 93/45
Pulse= 50
RR= 20
O2 sats= 97%
Pain= 8, low back
Temp= 94.4 auxiliary
Weight= 85 kg

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Classificati
on

Dose/Route/
Rate if IV

Onset/Peak

Intended
Action/Therapeutic
use. Why is this
client taking med?

Adverse reactions
(1 major side
effect)

Nursing Implications for this client. (No

more than one)

Furosemide
(Lasix)

Loop
Diuretic

2 mL IV
push

Onset- 5
min Peak30 min

Fluid Overload

Hypokalemia

Assess pt for dysrhythmias, weakness,

fatigue and muscle cramps.

Levothyroxin
e (Synthroid)

hormone

75 Mcg, 1
Tab PO

Onsetunknown
Peak-3-4
weeks

Replacement for
hypothyroidism

Headache

Assess type, location, and intensity of pain

Sertraline
(Zoloft)

Antidepres
sant

50 mg PO

Depression/anxiety

Dizziness

Teach patient to change positions

slowly.

Potassium
Chloride
oral tab SA
(Klor-Con
M)

Mineral
and
electrolyte
replaceme
nt

1 tab PO

Onset- 2-4
weeks
Peakunknown
Onsetunknown
Peak- 1-2
weeks

Prevention of
deficiency

Arrhythmias

Auscultate heart sounds throughout

therapy noting any abnormalities.

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.
Patient Values/
Date of care

Interpretation as related to
Pathophysiology cite reference & pg
#

Date

Lab Test
Normal
Values

2/24

Sodium
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
BUN
8-21 mg/dL

137

w/in range

4.1

w/in range

105

w/in range

26

w/in range

95

w/in range

51

Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
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

1.32

Congestive Heart Failure (Vann

Leeuwen and Bladh)
W/in range
8.5

w/in range

0.8

w/in range

5.6

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
WBC
4.5 11.0

2.9

Heart failure related to fluid retention

(Van Leeuwen and Bladh)
Malnutrition (Van Leeuwen and Bladh)

96

w/in range

39

w/in range

4.0

RBC

3.10

Bone Marrow Suppression (Van

Leeuwen and Bladh)
Chronic inflammatory disease (Van
Leeuwen and Bladh)

male: 4.7-5.14 x
10
female: 4.2-4.87 x
10

HGB
male: 12.6-17.4
g/dL
female: 11.7-16.1
g/dL

HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 32 Pg
MCHC
33-35 g/dL

8.9

Anemia (Van Leeuwen and Bladh)

28.0

Anemia (Van Leeuwen and Bladh)

91

w/in range

28.7

w/in range

31.7

Iron Deficiency Anemia (Van Leeuwen

and Bladh)

RDW
11.6-14.8%
Platelet
150-450

18.5
30

Iron deficiency anemia (Van Leeuwen

and Bladh)
Iron deficiency anemia (Van Leeuwen
and Bladh)

DIAGNOSTIC TESTING
Date

UA

Results

Interpretation as related to
Pathophysiology cite
reference & pg #

Normal
Range

Results

Interpretation as related to
Pathophysiology cite
reference & pg #

2.5-3.5

3.7

10-13
sec

40.9

Normal
Range

Color/Appearan
ce
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date

Other
(PT, PTT, INR,
ABGs, Cultures,
etc)

2/24

INR

2/24

Prothrombin
time

Date

Radiology
X-Rays
Scans
EKG-12 lead
Telemetry

Results

Vitamin K deficiency (Van

Leeuwen and Bladh)
Thrombocytopenia (Van
Leeuwen and Bladh)

Interpretation as related to
Pathophysiology cite
reference & pg #

DAR NURSING PROGRESS NOTE

Include the same note that was written in the client record for the priority nursing
diagnostic statement. Include the date/time/signature.
Date: 2/25/16 Time: 1145
Data: Patient is a 93-year-old man here for acute respiratory failure. He was on BIPAP all
morning and about 1140 the nurse and I took him off the BIPAP because he had a visitor.
Monitored him with the Pulse oximeter and he SpO2 dropped to 79%.
Action: The pt was asymptomatic, and did not appear in respiratory distress. We found a
nasal cannula and quickly hooked him up to 3 liters of oxygen and monitored his
saturation.
Response: Within five minutes his O2 sats were up to 90%.
Quinlyn Deming NS

PATIENT CARE PLAN

Patient Information:
Patient is a 93-year-old man who was admitted to the ER w/ SOB. He was diagnosed w/
acute respiratory failure and he also had iron deficiency anemia and CHF.
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).

Problem #1Impaired gas exchange r/t ventilation perfusion imbalance AEB confusion,
SOB, dyspnea, tachypnea, reduced tolerance for activity, hypoxemia, acute respiratory
distress.
Desired Outcome: Patient will show no signs of dyspnea and respiratory rate will be
maintained between 14-20 throughout my shift.
Nursing Interventions
Client Response to Intervention
1.Assess patients respiratory status including,
1.Pt was set up on BIPAP when I got
RR, depth, use of accessory muscles, O2 sats,
there in the morning, so his breathing
rhythm and lung sounds at the beginning of my rate was regular in rhythm, pt was not
shift and every two hours after that.
in respiratory distress, no use of
accessory muscles, O2 sats were 97%,
RR was 20. Later in the day I did
remove the BIPAP and there was a
decrease in O2 sats to 79% until a
nasal cannula was administered at 3
L/min and the sats came back up to.
Checking is respiratory status was very
important and a good intervention.
90%.
2.Provide oxygen therapy per doctors orders
2.Pt was on BIPAP most of my shift
via nasal cannula or facial mask as needed by
until it was time for him to eat then we
the patient and check O2 sats before
switched him to a nasal cannula. While
administration and every two hours throughout on the nasal cannula I did notice more
therapy.
difficulty breathing than w/ the BIPAP,
but his RR stayed between 16-20 and

3.Assist patient in position changes to promote

adequate breathing, bed should be at a 45
degree angle for optimum ventilation-perfusion
balance and ease of breathing.

his sats between 85%-94%.

3.We did a lot of position changes for
the patient today and it was very
successful. Changing the position
wasnt necessarily for ease of
breathing though, it was more for
comfort for the pt.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Overall I think this diagnoses and the interventions worked very well. I could have made
the r/t more specific by saying something like inadequate O2 in the bloodstream or
inadequate exchange of O2 into the bloodstream at the alveoli. All of my interventions
for this diagnoses were useful and important. I could have made the position change
intervention more specific and measurable by saying every two hours which is what I
ended up doing for the pt anyway.
Problem #2 Decreased Cardiac Output r/t altered heart rate and rhythm AEB CHF,
edema, crackles, fatigue, weakness, pulse of 53, BP of 105/63.
Desired Outcome: Patients heart rate will be between 60-100 and BP will be between
110/70-120/80.
Nursing Interventions
Client Response to Intervention
1.Assess patients heart rate, rhythm and BP at 1.Rhythm was regular, but bradycardic
the beginning of my shift noting any
varying from 40-50 throughout my
dysthymias or unstable BP and assess every
shift. BP was hypotensive at 93/45. It
two hours after that.
was stable w/in this range though and
did not drop to even more alarming
levels.
2.Palpate for peripheral pulses using a Doppler
2.Radial pulses were equal and strong
if necessary at the beginning of my shift and
bilaterally, pedal pulses were not
every two hours after that to assess blood flow
palpable to touch but located w/ a
to the extremities.
Doppler, strong and equal.
3.Elevate his legs anytime while lying in bed on
two pillows to help decrease the swelling in his
legs. If patient gets out of bed elevate his legs
on a stool or something similar.

3.Patients legs were elevated on two

pillows at all times. We even elevated
them in a way were his heels were not
exposed to pressure because he was
very edematous and at risk for
pressure ulcers.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
I think this diagnoses and interventions were very successful as well. I was worried about
the pts peripheral pulses because he was so swollen in his feet, so finding the pulses w/
the Doppler was definitely a positive intervention. I found that his decreasing heart rate
and BP was something that was a normal trend for him, due to nearing the end of life.
Problem #3 Activity intolerance r/t imbalance between oxygen supply and demand AEB
fatigue, weakness, respiratory failure, CHF.
Desired Outcome: Patient will walk from the bed to the bathroom (approximately ten
feet) with the use of an assisted device three times throughout my shift.
Nursing Interventions
Client Response to Intervention
1. Encourage the client to rise from a lying or
1.My patient was unable to walk at all
sitting position slowly and assure they are not
so this was unnecessary. However,

dizzy before beginning to walk every time I get

the patient out of bed or change positions.
2.Assess patients level of fatigue w/ exertion
and provide adequate rest periods as needed
every time I walk w/ the patient.
3. Teach patient how to properly use an
assistive device such as a walker and have him
teach back to me to show he understands.

changing from side to side in bed was

necessary and I did assess him for
dizziness or increased SOB and he was
asymptomatic.
2.I definitely had adequate rest today
considering he was bed bound, which I
did not know last night.
3.This was unnecessary for this pt
because he was bed bound.

Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
I do think my patient has an activity intolerance, but it definitely was not a priority
diagnoses for him. I found this morning that he was at/nearing end of life so it makes
sense that in his state he would have activity intolerance. I ended up spending more of
my day providing quality care, being a supporter for him, listening to his stories and
comforting him. So a diagnoses on quality of life, or comfort would have been more
valuable to him.