UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

| |Student: Miguel Martinez |

|Fundamental Patient Assessment Tool . |Assignment Date: July, 13, 14 |

| ( 1 PATIENT INFORMATION |Agency: SJH |

|Patient Initials: M. P. |Age: 57 Year Old |Admission Date: 07/ 17/14 |

|Gender: Female |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: |

|Primary Language: Spanish |Pneumonia, Organism Unspecified. |

| |ICD-10 Code J18.1 |

|Level of Education: 8th Grade |Other Medical Diagnoses: (new on this admission) |

|Occupation (if retired, what from?): Retired. Care Taker. | |

|Number/ages children/siblings: Sons: 31 yrs, 33 yrs, and 36yrs. Daughters: 38 yrs. |Brothers: 55 yrs and 57 yrs |

| |Sisters: 37yrs, 38 yrs, 53 yrs, 50 yrs, 56 yrs, and 60 yrs. |

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|Served/Veteran: No service |Code Status: Full Code |

|Living Arrangements: Patient lives in house with husband. |Advanced Directives: None |

| |If no, do they want to fill them out? Patient states "not interested" |

| |Surgery Date: Procedure: |

|Culture/ Ethnicity /Nationality: Hispanic, Puerto Rican. | |

|Religion: Pentecost |Type of Insurance: No insurance. |

|( 1 CHIEF COMPLAINT: |

| Patient states " I felt like I couldn’t breathe" |

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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |

|The patient is a 57 year old female Hispanic who presented to the St. Josephs Hospital emergency room with complaints of not being able to breathe. She was feeling|

|short of breath and dizzy during ambulation for about 5-6 days before coming into the hospital. The night before admission, the patient states she could not |

|breathe and when she woke up she felt like she was drowning and decided to come into the Emergency Room (ER). During physician assessment, the patient was found |

|to become dizzy during ambulation and was also coughing up clear phlegm. The patient does have history of asthma and thought it was an asthma exacerbation. When |

|questioned about medication for her asthma the patient indicated she sought inhalers from a friend to help her breathing trouble but the inhalers did not help. The|

|patient does have a history of hypertension, asthma and diabetes type 2. Patient does not have medications for none of past medical illnesses nor does she seek |

|routine doctor visits to manage her illnesses. Patient said she had breast cancer and was resolved with chemotherapy and mastectomy in 2007. Her baseline vitals |

|in the ER resulted in a pulse ox of 83% and were started on Bipap, antibiotics, Lasix and Nicardipine gtt as evidence by Systolic blood pressure of 190 during |

|admission. She was admitted into the ICU and had cardiac monitoring with Telemetry ordered as evidence by murmur and tachycardia during admission. Additionally |

|lovenox sq was ordered as prophylaxis for blood clotting. A preliminary chest xray of the patient was ordered and was positive for bilateral perihilar airspace |

|disease. Consult of radiology indicated bilateral perihilar airspace disease could be potential for hydrostatic pulmonary edemea, pnemonia, lung injury or |

|pulmonary hemorrhage. The patient was in critical care for about 85 minutes. White blood Count was 9.8 and did not indicate any infection. The patient was had |

|blood culture, urine antigens and viral panel ordered and resulted negative. Empiric Zosyn and Levaquin IV started on admission and continued during |

|hospitalization for treatment of possible severe community acquired Pneumonia-with unknown organism. Another chest Xray on 07/05/14 showed improvement of |

|aceration left lung pulmonary edema. Then a chest Xray on 7/7/14 shows residual bibasilar lung opacities improved compared to Xray on 07/05/14. Doctor came into |

|today to re-assess patient and stated clearer lungs of patient. During my shift patient was on 4 liters of 100% oxygen via nasal cannula as evidence by drop in |

|Pulse Ox to 70's when patient was taken off of nasal cannula to ambulate. Discharge of patient is pending, progress, testing and specialist recommendation. As of |

|now respiratory specialist has recommended further recuperation before sending the patient home. When I assessed the patient for pain, patient indicated throbbing |

|pain rated at pain level 8 out of 10 on right side of posterior thoracic cavity. Patient indicated relief of pain when she laid and applied pressure to that side |

|of her back. She indicated aggravation of pain when she coughs. The only treatment she has tried is Tylenol, which was ordered to be administered PRN for pain. |

|Patient did indicate feeling and breathing better than when first admitted. |

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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation

|Date |Operation or Illness |

|1983 |Tubal Litigation |

|1991 |Bladder (hernia) |

|2006 |Breast cancer resolved in 2007 with Chemo and Masectomy. |

|Patient states 7 years ago |Diabetes Type 2: Not taking medication but was started on Levemir 20 units with a .2 mL concentration subcutaneous 2xdaily when admitted|

|which calculates to 2007 |for present health illness. |

|Patient states 7 years ago |Asthma: Not taking medication but did begin repirtory therapy when admitted to hospital for present health illness. |

|which calculates to 2007 | |

|Patient could not recall |Hypertension |

|when she was told of her | |

|hypertension. | |

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|( 2|Age (in years) |

|FAM| |

|ILY| |

|MED| |

|ICA| |

|L | |

|HIS| |

|TOR| |

|Y | |

| |Which side of the family (maternal or paternal Age and date of onset of the disease process if available. |

| |Patient’s current disease process is found in the paternal side of the family. Her father had a health history of Asthma emphesema, diabetes, and hypertension. |

| |Patient was medically diagnosed with idiopathic Community Acquired Pneumonia (CAP). Patient also has history of Asthma, breast cancer, diabetes type 2 and |

| |hypertension. |

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|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations |X | |

|Routine adult vaccinations for military or federal service | |X |

|Adult Diphtheria (Date; Patient cannot recall date or year) |X | |

|Adult Tetanus (Date; Patient stated 10 years ago which would be 2004) |X | |

|Influenza (flu) (Date; Patient stated 3 years ago which would be 2011) |X | |

|Pneumococcal (pneumonia) (Date; Patient does not know of vaccine) |UKNOWN |UKNOWN |

|Have you had any other vaccines given for international travel or occupational purposes? Please List | |X |

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |Succinyl Choline |Patient airway closes up and during surgery of herniated bladder patient was intubated. |

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|Other (food, tape, latex, dye, | | |

|etc.) | | |

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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) |

|Mechanics of Disease: Pneumonia is an infection of the lower respiratory system that is usually caused by different organism including bacteria, viruses, fungi, |

|protozoa or parasites (Huether & McCance, 2012). There is Community Acquired Pneumonia (CAP) and hospital acquired Pneumonia (Nosicomial). The patient I assessed |

|was diagnosed with idiopathic CAP. However one of the most common causes of CAP is Streptococcus pneumonia, which leads to hospitalization of half of the |

|individuals infected with this type of pneumonia. On the other hand Nosicomial Pneumonia is a frequent complication people who are in Intensive Care Unit (ICU) and|

|especially those placed on mechanical ventilators. The most common pathogens that cause Nosocomial Pneumonia are Pseudomonas aeruginosa and Staphylococcus aureus |

|(Huether & McCance, 2012). Aspiration of orophayngeal sections is the most common route of lower respiratory tract infection. Infection can also begin by inhaling |

|microorganisms that are in air via coughs, sneezes, talking or from aerosolized water from devices such as respiratory therapy equipment. The most important cell |

|defenders of lower respiratory tract infections are alveolar macrophages. It recognizes pathogens through distinguished receptors and helps initiate innate or |

|adaptive immune responses. Alveolar macrophages release tumor necrosis factor-alpha and interleukin-1 with causes widespread inflammation in the lung and |

|recruitment of neutrophils from lung capillaries into the alveoli (Huether & McCance, 2012). Additionally macrophages can present antigens to adaptive immune |

|system to activate T and B cells. The inflammatory reactions and immune complexes can damage bronchial mucous membranes and alveoli capillary membranes with causes|

|bronchioles to fill with infectious debris and exudate. Some of the infecting microorganism can release toxins and cause further lung damage and consolidation of |

|lung tissue. As a result a person will have an accumulation of exudate, which leads to dyspnea, hypoxemia and mismatching ventilation and perfusion. |

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|Risk factors: Young children and elderly have an increased risk of contracting Pneumonia. Other risk factors include, compromised immunity, lung disease, smoking,|

|alcoholism, altered consciousness, impaired swallowing, endotracheal intubation, malnutrition, immobilization, cardiac or liver disease and finally being part of a|

|nursing home also is a risk factor for Pneumonia (Huether & McCance, 2012). |

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|How to diagnose: Diagnoses of pneumonia include procedures such as: Chest X-ray, white blood cell count, stains and cultures of respiratory tract secretions, blood|

|cultures and physical examination. Chest X rays help show infiltrates that may involve any part of the lung. Usually the white blood cell count is elevated or low |

|if person is debilitated or immunocompromised. Culture and blood cultures are used to help identify the pathogen. |

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|How to treat: Some treatments for Pneumonia vary by individual and by the type of pneumonia that the patient has contracted. One of the first steps in treatment |

|includes establishing adequate ventilation and oxygenation. Antibiotics are used to treat bacterial pneumonia(Huether & McCance, 2012). Empiric antibiotics are |

|chosen based on the causative microorganism and use of multiple broad-spectrum antibiotics may be used (Huether & McCance, 2012).Viral pneumonia has usually been |

|treated with supportive therapy and in some cases the use of antivirals and antifungal medication has been equipped to treat the more severe cases of |

|pneumonia(Huether & McCance, 2012). |

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|Prognosis: Pneumonia is the sixth leading cause of death in the United States. Most of the time pneumonia is in the upper airway system and will lead to infection |

|of the lower airway system if the person's immune system is degraded (Huether & McCance, 2012). With the proper antibiotics and treatments, patients with bacterial|

|pneumonia do recover. Usually viral pneumonia is mild and self-limiting but some medications also exist to help treat the person. However every case is different |

|depending on the person and their state of health. Like mentioned before the different factors put some people at a higher risk than others for contracting this |

|illness. Usually viral pneumonia is mild and self-limiting. |

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( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]

|Name Albuterol-ipratropium (Duoneb) |Concentration (mg/ml) 3 ml |Dosage Amount (mg) 50 mg |

|Route: Nebulizer |Frequency: q4h |

|Pharmaceutical class: Adrenergics |Home Hospital or Both |

|Indication: This medication is used as a bronchodilator to control and prevent reversible airways obstruction. The patient was prescribed this medication as a |

|control agent for her pneumonia and difficulty breathing. |

|Side effects/Nursing considerations: This medication is advised to use cautiously on this patient due to her history of hypertension and diabetes as it could |

|possibly make her hypersensitive to adrenergic amines. Some side effects to this medication include hyperglycemic, hypokalemic, angina, arrhythmia and |

|hypertension A life-threatening side effect is paradoxical bronchospasm, which is an exacerbation of wheezing or difficulty breathing (U.S. National Library of |

|Medicine. 2014). Some nursing considerations would include assessing the patient's pulmonary function and assessing the patients for paradoxical bronchospasm, as |

|medication will need to be withheld and provider notified. Further nursing consideration include educating the patient and family on the importance of taking the |

|medication as prescribed to reduce risk of side effects. Additionally, the patient should also know to contact provider if routine drug dose is not having any |

|effect. |

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|Name Arformoterol (Brovana) |Concentration 2ml |Dosage Amount 15 mcg |

|Route Nebulizer |Frequency q12h |

|Pharmaceutical class Adrenergics |Home Hospital or Both |

|Indication: This medication is used to prevent bronchospasm in people with chronic bronchitis, emphysema and COPD. The patient uses this medication to prevent |

|bronchospasm due to her pneumonia. |

|Side effects/Nursing considerations: These drugs can cause hypokalemia, leukocytosis, tachycardia, and insomnia. Some more life-threating side effects include |

|risk for asthma-related death and paradoxical bronchospasm. Some nursing considerations would be assessing the patient for signs of paradoxical bronchospasm, |

|swelling due to hypersensitivety. If either condition is observed the nurse would have to withhold medication and notify provider. Finally the nurse would have to|

|educate the patient on tkaing the medication as prescribed and notifying provider if difficulty of breathing continues. |

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|Name Asithromycin (Zithromax) |Concentration |Dosage Amount 500 mg |

|Route PO |Frequency 1xdaily |

|Pharmaceutical class: Macrolides |Home Hospital or Both |

|Indication: My patient was given this medication to treat her pneumonia, which was so far diagnosed as unknown organism. |

|Side effects/Nursing considerations: Some important side effects to look for in this medication include, seizures, dyspepsia, phyloic stenosis, vaginitis, |

|leukopenia, thrombocytopenia, otoxicity, and hyperkalemia. This medication has many life-threating side infects including, Torsades de pointes, hepatoxicity, |

|pseudomembranous colitis, Steven-Johnson syndrome, angioedema and toxic epidermal necrolysis. Some nursing consideration would be to assess for anaphylaxis, |

|infection, skin rashes, and lab work to check for increased serium bilirubin, AST, ALT, LDH and alkaline phosphatase concentrations. Finally the nurse would need |

|to educate the patient to report symptoms of any skin changes, chest pain, palpitation and foul smelling or loose stool. Most important the patient must notify |

|health care provider if fever and diarrhea develop and seeking advice to treat diarrhea. |

|Name Budesonide |Concentration 2ml |Dosage Amount 0.5mg |

|Route Nebulizer |Frequency q12h |

|Pharmaceutical class corticosteroid |Home Hospital or Both |

|Indication The patient was prescribed this medication in form of nebulizer to treat and maintain prophylactic therapy of asthma like symptoms related to pneumonia.|

|Side effects/Nursing considerations Some side effects include rashes, otitis media, oropharyngeal fungal infection, dyspepsia, gastroenteritis, adrenal suppression|

|and decreased weight gain. A severe life threating side effects is anaphylaxis. Some nursing considerations include assessing for respiratory status and lungs |

|sounds. Nurses would also teach patient to take medication as prescribed, and because this patient is using bronchodilators I would educate patient on taking |

|bronchodilators first and waiting five minutes before taking corticosteroid. It’s very important that patient knows to contact provider if anaphylaxis occurs. |

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|Name Clonidine |Concentration |Dosage Amount 0.2mg |

|Route po |Frequency q12hr |

|Pharmaceutical class Adrenergic (centrally acting) |Home Hospital or Both |

|Indication This medication will help patient with her mild to moderate hypertension. |

|Side effects/Nursing considerations Some side effects include, depression, hallucinations, dry eyes, AV block, hypotension, constipation, sodium retention and |

|paresthesia. Some nursing considerations include assessing patient blood pressure, pain and checking for drug withdrawal symptoms. I would also administer the |

|last dose at bedtime and ensure that the patient swallows the tablet whole. |

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|Name Enoxaparin (lovenox) |Concentration 0.4 ml |Dosage Amount 40 mg |

|Route Subcut injection |Frequency q24h |

|Pharmaceutical class Antithrombotic, low molecular weight heparin |Home Hospital or Both |

|Indication The patient was given this medication as a prophylaxis for Deep vein thrombosis, venous thromboembolism and pulmonary embolism. |

|Side effects/Nursing considerations Due to the patient’s unmanaged hypertension, this drug is to be used cautiously. Some side effects to look for are insomnia, |

|edema, constipation, urinary retention, alopecia, ecchymoses, urticaria, anemia, eosinophilia, and hematoma at injection site. Nursing considerations would be to |

|assess for bleeding, hemorrhage, output, and monitoring platelet count, and complete blood count. As for family and patient teaching, nurses would education |

|patient to report any unusual bleeding, bruising, rashes, or difficulty breathing. |

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|Name Furosemide (Lasix) |Concentration 4ml |Dosage Amount 40 mg |

|Route Iv Injection |Frequency q12hr |

|Pharmaceutical class loop diuretic |Home Hospital or Both |

|Indication This medication was given to patient to help with edema from pneumonia and hypertension. |

|Side effects/Nursing considerations Some side effects include blurred vision, tinnitus, anorexia, pancreatitis, polyuria, nephrocalcinosis, hypercholesterolemia, |

|hyperglycemia, hypovolemia, hyponatremia and metabolic alkalosis. Some life-threatening side effects erythma multiformse, stenves-johnson syndrome, toxic |

|epidermal, necrolysis, apastic anemia, and agranulocytosis. Nursing considerations include assessing patient, fluid status, appetite, and tinnitus, hearing loss |

|and skin rashes. Some lab values that need to be asses are serum glucose, potassium, uric acid, bun, calcium and magnesium. Patient and family teaching of the |

|patient includes advising patient to ontact health care professional if rash, muscle weakness, numbness or tingling of extremities occur. |

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|Name Guaifenesin (Mucinex) |Concentration |Dosage Amount 1200 mg & 600 mg at home |

|Route PO |Frequency q12hr |

|Pharmaceutical class Allergy, cold and cough remedies expectorant |Home Hospital or Both |

|Indication This medication was given to the patient for cough associated with her pneumonia. |

|Side effects/Nursing considerations: Some side effects include, uticaria, dizziness, stomach pain and vomiting. Nurses would teach family and patient the |

|important of coughing effectively. Nurses should also advice patient not to drive or do any other activity requiring alertness as this drug could cause dizziness. |

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|Name Insulin (Levemir) |Concentration 0.2ml |Dosage Amount 20 units |

|Route Sub cut injection |Frequency 2xdaily |

|Pharmaceutical class: Pancreatics |Home Hospital or Both |

|Indication This medication was given to patient to help control hyperglycemia due to her type 2 diabetes. |

|Side effects/Nursing considerations: Some side effects include lipodystrophy, pruritis, erythema, swelling and some side effects that could be life-threating |

|include hypoglycemia and anaphylaxis. Some nurisng considerations include assessing the patient for signs and symptoms hypoglycemia and monitoring body weight |

|periodically. Nurses should also clarify orders if they are confusing or difficult to understand. Nurse should not mix levemir with any other insulin type. The |

|nurse should teach patient's family and patient the proper technique of insulin administration, and its use to manage hyperglycemia and not having ability to cure |

|it. Additionally educate patient about hypoglycemia and what to do if does occur. Patient should also carry a source of sugar and be able to describe their |

|condition and treatment at all times. |

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|Name Insulin (Novolog) |Concentration |Dosage Amount medium dose |

|Route Sub cut injection |Frequency 3x daily AC+HS insulin sliding scale |

|Pharmaceutical class Pancreatics |Home Hospital or Both |

|Indication This was given to patient to help control hyperglycemia due to type 2 diabetes. |

|Side effects/Nursing considerations Side effects are similar to levemir in that patient could develop lipodystrophy , pruritis, erythem and swelling. Some more |

|life-threating side effects include hypoglycemia and anaphylaxis. Again the nurse should assess the patient fors sings of hypoglycemia and monitor weight. The |

|nurse should teach patient's family and patient the proper technique of insulin administration, and its use to manage hyperglycemia and not having ability to cure |

|it. Additionally educate patient about hypoglycemia and what to do if does occur. Patient should also carry a source of sugar and be able to describe their |

|condition and treatment at all |

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|Name Piperacillin (Tazobactim) Zosyn |Concentration 100 ml |Dosage Amount 3.375 mg |

|Route IV |Frequency q6hr |

|Pharmaceutical class extended spectrum penicillins |Home Hospital or Both |

|Indication This medication is used for treatment of appendicitis peritonitis, skin infection, gynecologic infection and community acquired and noscomonial |

|pneumonia. The patient was given this medication for treatment of community acquired pneumonia. |

|Side effects/Nursing considerations Some common side effects include, diarrhea, rahses, phelbits at IV site. Life-threatening side effects include, seizures, |

|pseudomembranous colitis, Stevens Johnson syndrome, toxic epidermal necrolysis, anaphylaxis and serum sickness. Nursing consideration include assessing patient for|

|infection, anaphylaxis, bowel function and skin reactions. Patient and family should also be educated on reporting signs of superinfection, fever and diarrhea, |

|which should prompt patient to contact health care provider. |

|Name Potassium chloride (Kdor20) |Concentration |Dosage Amount 20 mEq |

|Route PO |Frequency 1xdaily |

|Pharmaceutical class mineral and electrolyte replacements/supplements |Home Hospital or Both |

|Indication This medication is used to treat and prevent potassium depletion. This was given to patient to prevent hypokalemia due to albuterol and azithromycin. |

|Side effects/Nursing considerations Some side effects include abdominal pain, diarrhea, vomiting, and paralysis. Life-threatening side effects include arrhythmias.|

|Nursing considerations include monitoring serum potassium labs, assessing for hypokalemia, which indicates toxicity. The patient and patient's family should be |

|educated on importance of reading potassium level in other foods to avoid hyperkalemia. The patient should also be advised to contact provider if stool is blood, |

|feels tingling in extremities or has unusual fatigue. The patient should also be explained the importance of going to follow up appointments for serum monitoring. |

|Name Valsartan (Diovan) |Concentration |Dosage Amount 60 mg |

|Route PO |Frequency 2xdaily |

|Pharmaceutical class Angiotensin II receptor antagonist |Home Hospital or Both |

|Indication This medication is used to manage hypertension, treat hear failure and reduce risk from of death from cardiovascular causes. This was given to the |

|patient to help her manage her hypertension. |

|Side effects/Nursing considerations Some symptoms include dizziness, edema, pharyngitis, hyperkalemia, impaired renal function and arthralgia. Life-threatening |

|symptoms include angioedema. Nursing considerations include assessing the patient for angioedema, monitoring BP, and weight. Nurse should educate patient and |

|patient's family on taking medication as prescribed, avoiding salt substitutes, avoiding high potassium foods, the importance of following care plan recommended by|

|health care professional. Finally the nurse should instruct patient to contact health care provider if swelling occurs. |

|Name Diphenhydramine-ibuprofen |Concentration |Dosage Amount 38-200 mg |

|Route PO |Frequency 1xdaily hs |

|Pharmaceutical class Allergy, cold and cough remedies, antihistamines, |Home Hospital or Both |

|antitussives. | |

|Indication This medication is used to relief allergic symptoms, treat Parkinson's disease, as a mild nighttime sedation, motion sickness prevention medication and |

|antitisuve medication. The patient was given this to help prevent motion sickness which occurred during ambulation. |

|Side effects/Nursing considerations Side effects include blurred vision, tinnitus, hypotension, palpitations, anorexia, dry mouth, constipation, urinary retention,|

|dysuria wheezing and photosensitivity. Nurse consideration include assessing for anaphylaxis, motion sickness, pruritus and insomnia. Patient and patient's family |

|should be educated to take medication as prescribed, and education that medication may cause drowsiness, dry mouth to wear sunscreen and protection. |

|Name Albuterol (Proair HFA) |Concentration |Dosage Amount 90 mcg |

|Route Inhalation aerosol |Frequency 2 puff, q4hr for wheezing |

|Pharmaceutical class Adrenergics |Home Hospital or Both |

|Indication Used as bronchodilator to control and prevent reversible airway obstruction, used as quick -relief for acute bronchospasm and used as longer-term |

|control in patient with chronic bronchospasm. The patient was using mediation to help manage her asthma. |

|Side effects/Nursing considerations This medication is advised to use cautiously on this patient due to her history of hypertension and diabetes as it could |

|possibly make her hypersensitive to adrenergic amines. Some side effects to this medication include hyperglycemic, hypokalemic, angina, arrhythmia and |

|hypertension A life-threatening side effect is paradoxical bronchospasm, which is an exacerbation of wheezing or difficulty breathing (U.S National Library of |

|Medicine. 2014). Some nursing considerations would include assessing the patient's pulmonary function and assessing the patients for paradoxical bronchospasm, as |

|medication will need to be withheld and provider notified. Further nursing consideration include educating the patient and family on the importance of taking the |

|medication as prescribed to reduce risk of side effects. Additionally, the patient should also know to contact provider if routine drug dose is not having any |

|effect. |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Mechanically Soft |Analysis of home diet (Compare to “My Plate” and |

|Diet patient follows at home? Regular Diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: | My patient passed the recommended grain and protein guidelines. The patient did |

| |not meat the vegetable, dairy or fruit recommendations. More in detail the |

| |patient only had 53% of the recommended vegetables, 58% of recommended dairy, |

| |108% of recommended grains, 107% of protein and 0% of fruits. The patient had a |

| |total of 2,081 calories, which surpassed the 2000-calorie limit. Additionally the|

| |patient surpassed her saturated fat recommendation of 22gram with 35 grams and |

| |sodium recommendation of 2,300mg with 3,377mg. The patient was within limits of |

| |recommended oils of 6 tsp. with the patient consuming only 2tsp. |

| |Because the patient's diet does not meet the recommended guidelines I would have |

| |a dietician come and speak with her about future diet practices. Some changes to |

| |the diet would include reduction in total calories, saturated fat intake, and |

| |sodium intake. Furthermore created the patient a diet and I exchanged some of the|

| |patient’s choices like the fried chicken for 1 filet of tilapia and an ounce of |

| |tuna. To get more protein and diary products I exchanged the patient’s three cups|

| |of coffee with 1 cup of fat-free skim milk per meal and included reduced fat |

| |sausage turkey into the patient breakfast instead of butter scrambled eggs. To |

| |increase intake of vegetables, I included a salad in the patient's lunch, 1 cup |

| |of spinach and broccoli for dinner, and1 cup of carrots as a snack. To ensure |

| |proper fruit intake I included, a cup of raw blueberries and 1 medium raw orange |

| |in patient’s snacks. For grains I included oatmeal and 1 slice of whole wheat in |

| |patient breakfast, and 1 cup of brown rice for lunch and dinner. I helped make a |

| |diet for the patient that reduced her sodium intake, which is most important due |

| |to her hypertension and increased her nutritional intake to have a more balanced |

| |diet. |

|Breakfast: Patient indicated normal breakfast included: Small bowl of boiled | |

|oatmeal, scrambled eggs cooked in regular butter, bowl of rice crispy with a cup | |

|of coffee. | |

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|Lunch: Patient indicated normal lunch included: a bowl of brown rice, with 3 | |

|pieces of chicken and a roman noodles. | |

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|Dinner: Patient indicated normal dinner included: fried chicken with skin. A bowl| |

|of rice and black beans. | |

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|Snacks: Patient does have some chocolate flavored crackers. | |

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|Liquids (include alcohol): patient drinks about 7 cups of water a day, drinks 3 | |

|coffee with 2 sugars and milk. | |

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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |

| |average home diet to the recommended portions, and use “My Plate” as a reference.|

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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? Husband |

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|How do you generally cope with stress? or What do you do when you are upset? |

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|Patient states" House chores" |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|Patients stated feeling depressed the day before related to her desire to go home as she feels she has been here for many |

|days. |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

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|Have you ever felt unsafe in a close relationship? _Patient states "No"_ |

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|Have you ever been talked down to?__ Patient states "No"____ |

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|Have you ever been hit punched or slapped?  Patient states "No"____ |

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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|________ Patient states "No"______ If yes, have you sought help for this?  ______________________ |

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|Are you currently in a safe relationship? Patient states "Yes" |

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|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation X Generativity vs. X Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: |

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|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

| My patient is in the7th stage of Erikson’s psychosocial development stage, which includes Generatvitiy v.s. Stagnation stage. In the stage of Generactivity, the |

|person is usually working and contributing to society in someway. This is where the concern is in establishing and guiding the next generation (Schokilitsch & |

|Baumann, 2011). Some people may be helping raise children. However is the person does not find a way to feel like they are feeling productive than they may feel |

|self-absorbed in the state of stagnation |

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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|I think my patient is leaning more toward the stagnation state. She said she felt depressed because she was in the hospital for so long. Although she has older |

|children at this point in life, she was recently a caretaker, which gave her a sense of doing something productive for the future generation. Since she has been |

|here, that feeling of productivity has been taken away from her. She wants to go home and I saw this because when the doctors told her she might be staying longer |

|until she fully recovers she seemed down and somewhat depressed. I tried to comfort her by telling her that the doctors were only looking out for her own best |

|interest but she continued with wanting to go home. |

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|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|Patient states" I had a nightmare of a little Mexican girl being killed and ever since that dream I began to get sick." |

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|What does your illness mean to you? |

|Patient states" I do not know what caused it but they told me both of my lungs were infected and had liquid in the. I think |

|god is trying to reach out to me and get me to back to church like I used to" |

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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

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|Have you ever been sexually active? Patient states" YES" |

|Do you prefer women, men or both genders? Patient states "MEN' |

|Are you aware of ever having a sexually transmitted infection? Patient states "I do not know, I have not been checked" |

|Have you or a partner ever had an abnormal pap smear? NO |

|Have you or your partner received the Gardasil (HPV) vaccination? NO |

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|Are you currently sexually active?   YES |

|When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  Patient states" None |

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|How long have you been with your current partner? Patient states 35 years |

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|Have any medical or surgical conditions changed your ability to have sexual activity?  Patient states "NO" |

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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|Patient states "No" |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life? Patient states" None"

Do your religious beliefs influence your current condition? Patient states "Maybe, god may be calling me to him as I used to go to church a lot but have not been going for a long time"

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? |How much?(specify daily amount) |For how many years? X years |

|Patient states" NO" | Not applicable |(age thru ) |

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|Pack Years: Not Applicable | |If applicable, when did the patient quit? |

| | |Not applicable |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? Not applicable |

|Not Applicable |

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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? (give specific volume) |For how many years? |

|Patients states" I have a drink or two at parties but only every| Patient states" Drink vary from 2 (12 oz drinks) to |(age: 20 yrs old thru : 2014 |

|once in a while |mixed alcohol beverages the size of a cup." |) |

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| If applicable, when did the patient quit? | | |

|Patient state: " I currently drinks on occasion but says she does not drink a lot." |

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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? |

| |How much? |For how many years? |

| | |(age thru ) |

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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |

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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|Patient states " No" |

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( 10 Review of Systems Narrative

|General Constitution (OLDCART anything checked above) |

|Pt’s perception of health: Patient does feel like she has been eating less and has lost about 2 to 3 pounds since she's been sick. |

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|Integumentary: The patient states having some rashes with an itching sensation on both her legs, dandruff and bathing at least once a day. Patient denies having |

|changes in skin appearance, nail problems, psoriasis, skin infections or using sunscreen. |

|HEENT: The patients claims having sight difficulty, sinus pain, nose please, and post-nasal drip due to nasal cannula. Patient also claims brushing teeth twice a |

|day but having dental problems due to lack of dental visits. Patient indicated vision screen in 2011. Patient denies cataracts, hearing difficulty, ear infection, |

|oral/pharangeal infection or routine dental visits. |

|Pulmonary: The patient indicates having difficulty breathing, asthma, pneumonia and productive coughing. The patient also indicated having her last CXR on Tuesday |

|7/9/14. The patient denies having bronchitis, emphysema, tuberculosis or environmental allergies. |

|Cardiovascular: The patient does indicate having hypertension. The patient also had her last EKG screening on June 30, 2014. The patient denies having |

|hyperlipidemia, angina, MI, CAD, CHF, Murmur, thrombus, Rheumatic fever, Myocarditis, Arrhythmias. |

|GI: The patient denies Nausea, vomiting diarrhea, constipation, GERD, indigestion, hemorrhoids, jaundice, pancreatitis, colitis, diverticulitis, appendicitis, |

|abdominal abscess, irritable bowel, cholecystitis, gastritis, ulcers, hepatitis or blood in stool. |

|GU: The patient does indicate having an abnormal polyuria. The patient denies nocturia, dysuria, hematuria, kidney stones, bladder or kidney infection. |

|Women/Men Only: The patient indicated having stopped menstruating in 2002, which is due to menopause after having her tubal litigation. The patient did state having|

|menarche when she was 11 years old. The patient also stated having her last mammogram in 2006. The patient denies irregular menstruation, infection of the female |

|genitalia, monthly self-breast examination and a DEXA Bone density exam. |

|Musculoskeletal: The patient indicated having posterior thorax pain on her right side. The patient denies injuries, fractures, weakness, gout, osteomyelitis and |

|arthritis, |

|Immunologic: The patient has night sweats and has a severe allergy to succinyl choline. She denies having chills with sever shaking, fever, HIV, AIDS, lupus, |

|Rheumatoid arthritis, sarcoidosis, tumor, or enlarged lymph nodes. |

|Hematologic/Oncologic: The patient does not have anemia, bleeding easily, bruising easily, having cancer at the present moment or having had a blood transfusion. |

|Metabolic/Endocrine: the patient does have Diabetes Type 2, and is recently intolerant to the hot. The patient does not have a hypothyroid or hyperthyroid, |

|osteoporosis or intolerance to cold. |

|Central Nervous System: The patient indicates feeling dizzy during ambulation. The patient does not have a Cerebrovascular Attack, severe headaches, migraines, |

|seizures, tick or tremors, encephalitis, or meningitis. |

|Mental Illness: The patient has been feeling depressed in the past days. The patient does not have schizophrenia, anxiety or bipolor. |

|Childhood Diseases: The patient did have measles and chicken pox as a child. The patient did not have mumps, polio, or scarlet fever as a kid. |

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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

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|The patient states "No". |

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|Any other questions or comments that your patient would like you to know? |

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|The Patients states "No" |

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|±10 PHYSICAL EXAMINATION: |

|General survey: The patient is a 57 y.o. female who is alert & oriented X3. She seems to in pain as she continues to move and lean on her right side. |

|Height: 63 inches Weight: 84 kg BMI: 33 Pain (include rating and location):8/10 on Posterior thoracic right side Pulse: 77/minute Blood Pressure (include location): |

|Left arm, 114,71 Temperature (route taken): Oral, 98.3 |

|Respirations: 19/minute SpO2: 94% Room Air or O2: 4 litters of 100% O2 |

|Overall Appearance: The patient was clean, groomed maintained eye contact and was dressed appropriate for setting and temperature. The patient did not present any |

|obvious handicaps. |

|Overall Behavior: Overall the patient was calm and interacted well with other and presented an intact judgment. The patient did seem to indicate backside discomfort |

|as she continually repositioned her self on her right backside. |

|Speech: The patient had clear and moderate speed crisp diction. |

|Mood and Affect: The patient was pleasant and cooperative. |

|Integumentary: The patient’s skin was warm, dry and intact. Her skin turgor was elastic and had no rashes, lesion or deformities on skin. The patient’s nails did not|

|present with clubbing and her capillary refill was less 3 seconds. The hair was evenly distributed, clean and without vermin. |

|IV Access: The patient had a 20 gauge IV PICC line on her right upper arm. She was infused with Piperacillin/Tazobactim 3.375 grams over 30 minutes at a rate of 200 |

|ml/hr q6hr. |

|HEENT: The patient had symmetric facial features, clear conjunctiva without discharge, a white sclera, and a midline trachea. The patient’s eyes were symmetric and |

|intact without any lesion or discharge. Additionally the patient’s pupils were PERRLA and left and right eye were 3mm in size. The patient’s peripheral vision was |

|intact and their EOMs were also intact through 6 cardinal fields without nystagmus. The patient did not have pain in sinus region, nor did she have an enlarged |

|thyroid or palpable lymph nodes. She also did not have pain or clicking of TMJ. The patient’s eyebrow, eyelids, orbital area, eyelashes and lacrimanal glands were |

|symmetric and present without edema or tenderness. The patient whisper test heard: right ear- 6 inch & left ear 6 inches. The patient’s nose did have some discharge|

|but not visible lesion. The patient's lips, buccal mucosa, floor of mouth and tongue were moist and without lesions. |

|Pulmonary/Thorax: The patient respirations were regular and unlabored with symmetric chest expansion. The patient transverse to AP ratios was 2 to 1. The patient’s |

|lung sounds were clear to auscultation without adventitious sounds. When percussed the patient's lung field sounds were resonant and dull towards posterior bases. |

|The Sputem produced by the patient was small and clear. |

|Cardiovascular: The patient pericordium had no lifts, heaves or thrills. The patients PMI was not palpable. The patients hear sounds were regular and S1 and S2 were|

|also heard. No JVD or heart murmurs, clicks or adventitious heart sounds were heard. The patient was not on TELE. All of patient pulse's were equal bilaterally and |

|palpable +2. The patient had negative calf pain bilaterally. The patient had no temporal or carotid bruits or edema. Patients extremities were warm with a capillary |

|refill less than 3 seconds. |

|GI: The patient’s bowel sounds were active x 4 quadrants with no bruits present during auscultation. The patient did not have organomegally. During percussion, |

|spleen and liver had dull sounds. The stomach and intestine had tympanic sounds when percussed.. The abdomen was non-tender to palpitation. The patient stated urine |

|output was clear and had a light yellow tint. The patient did not have a Foley catheter, urinal or bedpan. The patient did have bathroom privileges with assistance |

|to her bedside commode. The patients CVA punch did not have rebound tenderness. The patients state last BM was formed and light brown. |

|GU: The patient was alert, oriented and denied problem with genitalia. |

|Musculoskeletal: Patient had full and intact range of motion bilaterally in all extremities without crepitus. The patient had a strength rating of 5/5 in all upper |

|and lower extremities bilaterally. The patient’s vertebral column was present without kyphosis or scoliosis. The patient’s neurovascular status intact with all |

|peripheral pulses palpable, no pain, no pallor, no paralysis or paresthesia present. |

|Neurological: The patient was awake, alert, oriented to person, place, time and date. The patient was not confused. The patients Cranial nerves 2-12 were grossly |

|intact. The patient’s sensation was intact to touch, pain and vibration was not assessed. The patient had a negative Romberg. The patients stergnossis, |

|graphesthesia, proprioception was intact. The patients gait was smooth regular with symmetric length of the stride. The patients deep tendon reflexes were not |

|assessed due to unavailable equipment. |

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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

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|Lab |

|Dates |

|Trend |

|Analysis |

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|WBC |

|9.8 |

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|8.3 |

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|Normal (4.5-11) |

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|(06/30/20014) |

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|(06/07/2014) |

|The lab values listed are those taken upon the patient’s arrival. Although within normal limits patients WBC did begin to decline |

|This is the number of infection fighting cells. High WBC indicates the presence of an infection or inflammation. High WBC is often indicated in presence of an |

|infection such as pneumonia. However, low WBC could also indicate a problem in WBC production, severe infection or other factor having an infection on the number of|

|WBC. |

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|HGB |

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|14 |

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|12.6 |

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|Normal: (12.0-16.0) |

|(06/30/20014) |

|(06/07/2014) |

|This lab value is the count of how much hemoglobin is in blood. Hemoglobin is a protein in red blood cells that carry oxygen. The patient hemoglobin was within |

|normal limits but declined by the second count. |

|The patients HGB count is within normal limits. Sometimes HGB count may be ordered if patient is feeling poor of health like this patient who has pneumonia. Having |

|low HGB could indicate having anemia, poor nutrition, malfunctioning bone marrow or chronic kidney disease |

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|HCT |

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|42.2 |

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|37.7 |

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|Normal: (37.0-47.0 |

|(06/30/20014) |

|(06/07/2014) |

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|This lab values are within the normal range limit for this particular count. The patient did have a small decrease in the number of hematocrit. |

|This lab value indicates the amount of whole blood that made up of read blood cells. Having to low hematocrit may be due to anemia, bleeding, malnutrition, leukemia,|

|overhydrating or nutritional deficiencies. High hematocrit could signify a congenital heart diease, dehydration, low blood oxygen, pulmonary fibrosis or bone marrow|

|disease. |

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|PLT |

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|278 |

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|261 |

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|Normal: (140-450) |

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|(06/30/20014) |

|(06/07/2014) |

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|The patients PLT count was kept within normal range limits. She was administered a prophylaxis to help prevent deep vein thrombosis, pulmonary embolism and |

|thromboembolism. |

|This lab value indicates the number of platelets that the patient has. If the patient has a low platelet count this may be due to platelet destruction, poor platelet|

|production or platelet production alteration due to drugs or medicine; this could result in increased chance of bleeding. A high platelet count could be due to |

|cancer, medication, spleen removal, chronic myelogenous leukemia, polycythemia vera or primary throbcythemia. A high count could increase the risk of developing |

|blood clots. |

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|NA |

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|137 |

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|136 |

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|Normal: (136-145) |

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|(06/30/20014) |

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|(06/07/2014) |

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|The patient sodium count did not change tremendously. In fact it remained within normal limits. |

|This lab value is the amount of sodium within the patient blood serum. A low count medically known as hypernatreiam, may be due to adrenal gland problems, |

|dehydration, urine build up or increase in total body water. A high count may be due too much salt intake, increased fluid loss, medication and problems with |

|adrenal gland. |

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|K |

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|3.9 |

|3.5 |

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|Normal: (3.5-5.1) |

|(06/30/20014) |

|(06/07/2014) |

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|The patients Potassium count remained within normal limits. It changed very little from the first potassium count. |

|This value is the count of potassium. Potassium is important because it helps the nerves and muscle communicate. It also helps cells absorb nutrients and remove |

|waste. It is important to keep this balance because this could have a mortal impact on the heart muscle as well. |

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|CL |

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|101 |

|98 |

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|Normal: (98-107) |

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|(06/30/20014) |

|(06/07/2014) |

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|The patients chloride stayed within normal limits. There was a small decline in the second count but nothing of major concern. |

|This value is the count of chloride in a person serum. Chloride is an important electrolyte that helps keep the proper balance of body fluids and helps maintain the |

|body’s acid base balance. Any disturbance in fluid or acid-base balance could disrupt the body's homeostasis. |

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|CO2 |

|27 |

|31 |

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|Normal: 21-32 |

|(06/30/20014) |

|(06/07/2014) |

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|The patients CO2 count remained within normal limits. This second count indicated the patient CO2 went up. |

|This lab value is the count of Carbon Dioxide in a persons body. ITs is important because CO2 makes up part of the blood. However keeping the patients CO2 within |

|normal limits is very important as the patient could cause an imbalance in the body's electrolytes. |

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|BUN |

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|13 |

|18 |

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|Normal: (6-26) |

|(06/30/20014) |

|(06/07/2014) |

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|The patients Blood urea nitrogen was again within normal limits. The second count was a litter higher than the first time. |

|This lab values is the count of Blood Urea Nitrogen in a person body. It is formed after body breaks down protein. This lab value could also be tested in urine to |

|see if kidney are functions as they are suppose to be. |

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|CREAT |

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|.4 |

|.61 |

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|Normal: (.30-1.30) |

|(06/30/20014) |

|(06/07/2014) |

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|The patients’ creatinine is within normal limits. The first and second counts fluctuated minutely. |

|This lab value is the count of creatinine in blood. This is asses to ensure that a person’s kidney are functioning like they are supposed to. |

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|BG |

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|268 |

|127 |

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|Normal: (70-99) |

|(06/30/20014) |

|(06/07/2014) |

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|The patient's Blood glucose was elevated for both counts. The first count indicates the patient was hyperglycemic. The patient was later given insulin, which help |

|reduce the blood glucose count to lower count. Even though the second count is also high, it could indicate the patient had recently eaten. |

|The lab value indicates the amount of serum glucose. It is very important, as glucose is cells energy. The amount of glucose in the blood could help diagnose whether|

|a patient's insulin is sufficient for the body's demand. |

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|CXR: |

|(06/30/14) Bilateral perihilar airspace disease. |

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|(07/05/14) Improved acration left lung, pulmonary edema pattern improved. |

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|(07/07/14) Residual bibasilar lung opacities improved. |

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|(06/30/14) |

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|(07/05/14) |

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|(07/07/14) |

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|The patient was first diagnosed with having perihilar airspace disease, which is usually indicative of pulmonary edema (Centers for Disease Control and Prevention |

|[CDC] (n.d). Haven been treated with albuterol, arformoterol and oxygen therapy, the patients lungs began to appear with less edema. |

|Lungs are normally clear when auscultated and when viewed via a radiology exam. If fluid is present in the lungs it is of concern because the patient could aspirate |

|on the fluid. |

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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

|The patient had several Chest X-rays to assess her lungs. She was found to have pulmonary edema, which was attributed to pneumonia. A blood culture, urine antigens |

|and viral panel were ordered. Although the provider was not able to identify the organism, the patient was diagnosed with community-acquired pneumonia. The patient |

|was also put on oxygen 4 liters with oxygen of 100% to help dilate her airways and to help her breathe better. The nurses were also instructed to notify physician if|

|patient began to have chest pain. Because the patient had unmanaged diabetes type 2, the provider ordered the patient blood glucose to be checked via accu check |

|q6hrs to 4x daily. The patient had a consult with nutrition, physical therapy, and pharmacy. The patient was ordered a mechanically soft diet to help prevent |

|aspiration. The patient was instructed to ambulate with assistance, as she would become dizzy when ambulating on her own. The patient also had a 20 gauge PICC line |

|was also ordered for the patient so that IV antibiotics could be administered via an IV pump. She also had a nebulizer medication to help her airways dilate. |

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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

|1. Activity intolerance related to imbalance between oxygen supply and demand as evidence by patient's pulse ox dropping to 70's % when taken off nasal cannula and |

|patient verbalization of having trouble breathing and feeling like she is drowning. |

|2.Impaired gas exchange related to decrease functional lung tissue as evidence by patient's pulse ox dropping to 70's % when taken off nasal cannula and patient |

|verbalization of having trouble breathing and feeling like she is drowning. |

|3. Imbalanced Nutrition related to loss of appetite evidenced by patient verbalization of loss of weight in past days and loss of appetite. |

|5. Ineffective airway clearance related to inflammation and presence of secretions as evidence by patient coughing up clear sputum. |

|6. Deficient knowledge related to risk factors predisposing patient to pneumonia as evidence by patient verbalization of lacking management of past medical health |

|history. |

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± 15 CARE PLAN

Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidence by patient's pulse ox dropping to 70's % when taken off nasal cannula and patient verbalization of having trouble breathing and feeling like she is drowning.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day care is Provided |

| | |Provide References | |

|By the end of my shift I would like my patient to |I would keep my patient on a nasal cannula with 100% |Patients with oxygen therapy help people function |The patient was put on 100% oxygen at a rate of 4 |

|verbalize an improvement in breathing measured by |oxygen and at a rate of 4 liters. I would also |better and become more active (National Heart, Lung |liters. The patient was able to verbalize that she |

|indicating a breathing difficulty of 3 or lower on a |instruct my patient on how to position the nasal |and Blood Institute, n.d). A patient should be |was breathing better. When I assessed the patient for|

|scale from 0 to 10. |cannula at the most comfortable position. I would |involved in their healing to make them feel more |difficulty of breathing, she indicated a 0. The |

| |also educate my patient on the importance on keeping |comfortable with care provider. Having the patient |patient did request assistance with ambulation. She |

| |the nasal cannula on. Additionally I would instruct |request assistance with ambulation will help the |also verbalized her understanding of not being able |

| |my patient to call for assistance when ambulating to |patient prevent falls that could cause even further |to ambulate on her own. Due to time constraints I was|

| |avoid injury. I would assess my patient on difficulty|damage to patient. |only able to assess my patients breathing one time. |

| |of breathing at least q2hrs during my clinical shift.| |On another day I would ensure to have timers set for |

| | | |myself to check up on patient. |

|By the end of my shift I will check the patient q4hrs|I would keep my patient on 100% oxygen at a rate of 4|Assessing a patients arterial ox hemoglobin |The patients had a pulse ox higher then 95% but when |

|to ensure my patient is able to maintain a pulse ox |liters unless otherwise indicated by provider. I |saturation proves provider with constant data, shows |the nurse took the patient off oxygen to ambulate, |

|of 95% when patient is ambulating for at least 5 |would have patient tech care assess the patients |trends and allows clinicians to intervene before the |the patients pulse oxygen dropped to 70's. So the |

|minutes without oxygen. |vitals q4hrs and verify that the patient's pulse ox |patient becomes unstable( Mininni, Herzer, Marino, & |goal would need to be readjusted so that the patient |

| |is 95% or higher. I would document the patients pulse|Kohler, 2009). Assessing the patient would also help |could at least verbalize being able to breathe better|

| |ox reading to visualize a trend on the patients pulse|pinpoint any patterns that could lead clinicians to |while ambulating with oxygen. Setting the goal to |

| |ox readings. I would then take my patient off oxygen |resolve the cause of the low arterial oxygen level. |keeping the patients pulse ox at 95% and higher will |

| |for 5 minutes to see if patient can ambulate while | |take some time and more oxygen thearpy. Until the |

| |maintaining a pulse ox of 95% or higher. | |patient's pneumonia begins to cure, the patients |

| | | |pulse ox will continue to drop. |

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|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|X SS Consult |

|X Dietary Consult |

|PT/ OT |

|X Pastoral Care |

|X Durable Medical Needs |

|□F/U appointments |

|X Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |

|□Rehab/ HH |

|□Palliative Care |

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|I would have a Social Services consult my patient for potential medical insurance plans that may be available to her to utilize to manage her chronic illnesses of hypertension, asthma and most importantly diabetes. I |

|would also have a dietary consult for my patient should the she could be educated on ways to maintain a healthy balanced diet on a low budget income. I would have a pastoral care come to talk with my patient as she is|

|showing interest in religion and having a clergy member talk to her would properly help with her recently self-identified depression. I would be having durable medical needs for this patient as patient may need to be|

|sent home with oxygen tank as her pneumonia conditions alleviates. I would also have a med prescription on her medication to manage her hypertension, asthma and diabetes. I would also have instructions for the patient|

|in Spanish as this is the patient first language. |

References

Davis’s Drug Guide. (Albuterol, Arformoterol, Azithromycin, Budesonide, Clonidine, Enoxaparin, Furosemide, Guaifenesin, Levemir, Novolog, Potassium Chloride, Diphenhydramine). Nursing Central.

Retrieved from 

Huether, S. E. & McCance, K.L. (2012). Understanding Pathophysiology. St. Louis, Missouri: ELSEVIER.

National Heart, Lung and Blood Institute. (n.d.). What is oxygen Therapy? Retrieved from

Schoklitsch, A. & Baumann, U. (2011) Measuring Generativity in Older Adults. Geropsych, 24, 31-43. doi:

10.1024/1662-9647/a000030

United States Department of Agriculture. (2012). . Retreived from ------asdfgh

 

U.S National Library of Medicine. (2014). Mometasone(by breathing) Retrieved from

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