Question

1: (Patient Case): T.C. is an 85 yr-old female admitted for COPD Exacerbation. The patient presented with worsening dyspnea and wheezing over the last 2 weeks, and a productive cough. The patient regularly uses oxygen at home. The patient lives alone in an apartment on the 4th floor (no elevator in the building). Patients’ neighbor brought her into the ED when she noticed the patient having trouble getting up the stairs to her apartment after going down to the first floor to do laundry. The patient has not really been able to get out of her house in the past 4 weeks to purchase goods including food, or to renew her prescriptions. Daily weights have been ordered. (Medical/Surgical History): COPD, Emphysema, Smoker x 50 years (still currently smoking ½ pack per day), Hypertension, Hyperlipidemia, Morbid Obesity, and Bilateral Knee Replacement.(Admission Vital Signs): T-38.4 C/101.2 F, HR-110, RR-25, SpO2-89% on 4L oxygen with a nasal cannula, BP-185/92, weight 113.4 kg/250 lb, height-5’2”(Physical Assessment): (Neuro) A/O x 4, (Respiratory) Crackles/Rhonchi in lung fields bilaterally with thick green sputum, (Cardiovascular) Irregular, S1 & S2 heard, (Integumentary) Stage II sacral ulcer & +3 pitting edema of lower extremities bilaterally, (GI) Active bowel sounds in all 4 quadrants/diarrhea x 4 days, (GU) new finding of urinary retention/it’s been 4 hours since she urinated, (Musculoskeletal) Generalized weakness/uses a cane to ambulate to the toilet with 2-person assistance(Radiology): Chest x-ray shows diffuse opacities bilaterally (abnormal)(Labs): WBC 14.18, Hgb 8.5, Hct 29, Glucose 287, CO2 10(Current Medications): Prednisone 20 mg daily, Montelukast 10 mg daily, Aspirin 81 mg daily, Hydrochlorothiazide 25 mg twice daily, Symbicort 160 mcg 2 puffs twice daily, ProAir 1 puff every 6 hours PRN, Breo Ellipta 200/25 mcg 2 puffs daily Use the Patient care concept map template to answer the components of the following question of the concept map i. Individual's information 1. Age 2. Medical diagnosis 3. A brief review of underlying pathophysiology *List what functional changes are happening *List process that initiated and maintained disorder or disease ii. Assessment Data 1. Include all assessment data, not simply information that supports the selected nursing diagnoses Inspect Palpation Percussion Auscultate Neurologica iii. Nursing Diagnoses 1. Select three nursing diagnoses to addresses a. One must be an actual problem b. One must address a psychosocial need c. The final must be a high priority for the individual iv. Linkages Within and Between Diagnoses 1. The concept map demonstrates relationship within and between the nursing diagnoses. v. Planning 1. Prioritize diagnoses to reflect the needs of the individual 2. Set realistic outcome measurement 3. At least two (2) scholarly, primary sources from the last 5 years, excluding the textbook, are provided vi. Implementation1. Interventions are individualized for patient-provider rationale 2. Interventions support the achievement of selected outcome measurements-provide rationale 2 NR226 Fundamentals – Patient Care RUA: Concept Map _RUA_Concept_Map vii. Evaluation of Outcomes (5 points/15%) 1. Determine if outcomes were met. 2. Provide evidence that supports that determination. 3. Describe what changes, if any, are needed to promote expected outcomes in the future. viii. Safety-Communication-Infection Control a. specific elements of communication used when providing care, b. safety concerns related to the individual for whom you cared, and c. infection control practices followed while caring for this patient.

Answer 1

1.COPD exacerbation is an acute event in the natural course of the disease . The primary causes of exacerbations are bacterial or viral infections. Exacerbations are signalled by an acute change in patient's usual dyspnea, cough/sputum

Classic signs of exacerbation include:

• Increase in dyspnea and cough
• Sputum volume/sputum purulence

They may also have non-specific complaints of malaise, insomnia, fatigue,depression, confusion,decreased exercise tolerance, increased wheezing or fever without other causes

The severity is determined by the patient's medical history before the exacerbation, the presence of other diseases, symptoms,ABGs and other laboratory tests

ABG values in the latter stages of disease:

• Low-normal pH
• High-normal or above normal pH
• High-normal or above normal PaCO2
• High-normal bicarbonate

This indicates compensatory respiratory acidosis as the patient has chronically retained CO2 and the kibneys have bicarbonate to increase the pH to within the normal range

2. Assessment data

Objective data

General

Debilittion, restlessness,assumption of upright position

Integumentary system

Cyanosis(bronchitis), pallor or ruby color, poor skin turgor, thin skin, digital clubbing, easy bruising, peripheral edema

Respiratory

Rapid shallow breathing; inability to speak; prolonged expiratory phase; pursed lip breathing; wheezing, rhonchi,crackles, diminished or bronchial breath sounds; decreased chest excursion and diaphram movement; use of accessory muscles; hyper resonnat or dull chest sounds on percussion

Cardiovascular

Tacycardia, dysrhythmias, jugular venous distention, distant heart tones, right-sided S3(cor-pulmonale),edema of the feet

Gastrointestinal

Ascites, hepatomegaly(cor pulmonale), hyperactive bowel sounds due to diarrhea heard on all quadrants

Musculoskeletal

Muscle atrophy, increased anteroposterior diamaeter

3. Nursing diagnoses

Ineffective airway clearance related to excessive mucus, retained secretions as evidenced by dyspnea , adventitious breath sounds(wheezes,rhonchi,crackles)

Goal

Client will maintain patent airway with clear breath sounds

Interventions

Interventions	Rationale
1.Auscultate breath sounds. Note adventitious breaht sounds such as wheezes, crackles or rhonchi 2.Assist client to maintain a comfortable postion such as elevating the head-end of the bed leaning on over-bed table sitting on edge of bed 3.Encourage and assist with abdominal and pursed-lip breathing	1.some degree of bronchospasms are present with obstructions in airway and manifested as adventitious breath sounds 2. elevation of head end of bed may facilitate respirations under the effect of gravity 3.Provides client with some degrees to cope with and control dyspnea and reduce air trapping

Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by dypnea, confusion,restlessnes, abnormal ABGs

Goal

Client will participate in treatment regimen within the level of ability and situation

Ineffective self-health management related to perceived benefits/seriusness as evidenced by failure to take action to reduce risk factors

Goal

Clent will verbalize understanding of condition,disease process and treatment

Interventions

rationale

1.Explain and reinforce explanations of individual disease process, including factorss that lead to excacerbation episodes 2.Discuss respiratory medications, side effects, drug interactions and adverse reactions 3.Encourage client to monitor own status using CAT questionnaire(evaluates, cough, mucus production, chest tightness, ability to rest etc) and to relay information to health care providers

1.Understanding decreases anxiety and increase participation in treatment plan 2.Frequently they are own various respiratory medicines which have similar side effects. Knowledge about each drug help them to difernetiate symptoms 3.This self-administerd questionaire helps the client monitor own respiratory status and changes that may be indicative of improvemen or need for medical evaluation