Question

Nursing Care Plan Assignment (1,2&3) Case Study Linda Shaw is a 56-year-old female who was brought to the hospital by EMS on December 23, 2019. She presented to the emergency department with complaints of shortness of breath. She has had a productive cough for 3 days with a fever. She is admitted to the hospital with pneumonia and septicemia. She has a history of cellulitis, iron deficiency, high cholesterol and hypertension. She has an allergy to penicillin and vancomycin. She is taking ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily. Since her arrival to hospital she has been on IV ceftriaxone 1gm q24 hours. She has been admitted for 2 days on the medicine unit that you are working on. Upon your assessment of the patient you notice she is short of breath during the interview. She can get no more than two words out before having to stop talking and rest. She is on wall oxygen at 2L via nasal prongs. You use your stethoscope to auscultate her chest and note decreased breath sounds to the LLL. You are aware that she has a left-sided pneumonia. You ask her to sit up in the bed and notice that she becomes increasingly short of breath with bed mobilization. Her respiratory rate is 24/min with evidence of accessory muscle use (abdominal breathing). You assess her oxygen saturation to be 92% on 2L of oxygen via nasal prongs. When asked if she has any pain the patient states “I have a heavy feeling in my chest”. You ask her what makes this pain worse, Linda states “The pain is worse when I am coughing”. You ask Linda when she first noticed the pain, “I first noticed the pain at 5am today”. Linda mentions that the pain in her chest seems to move into her throat. You ask Linda to describe the pain in her throat, “it is a scratchy pain”. Linda states that since changing her position on the bed she feels less pain. Linda states “before you asked me to move up in the bed my pain was 7/10 but since moving it is now 2/10 and mostly gone from my throat”. You assess Linda’s heart rate to be elevated (99 beats/min). You auscultate her apical pulse to match that finding. You note that her pulse is regular. You assess her blood pressure to be 111/80. You compare that to the blood pressure that the previous nurse had obtained overnight. Her pressure overnight was 118/79. You recognize that her blood pressure is lower than normal and ask her if she is dizzy or lightheaded, she tells you that she is not. Linda is alert and oriented and answering questions appropriately with no evidence of confusion. Upon assessment you note her pupils are equal and reactive bilaterally. Linda explains to you that she is feeling “unwell and tired”. She expresses frustration with her inability to sleep due to noise in the hallway at night. She tells you that she overheard the nurses talking all night long about baking Christmas cookies and it made her sad because she may not be home for Christmas. While Linda is talking to you about her inability to sleep, you notice that her oxygen saturation remains 92% despite her obvious shortness of breath when talking. Also, while she is talking to you, you take a look at her skin tone and note a normal skin colour and normal skin temperature. She does have dried blood at the site of her IV and the dressing is not intact. You assess her temperature to be elevated at 39 degrees Celsius. Linda also expresses frustration to you about being constipated, “I think I need some bran flakes. I haven’t had a bowel movement in 2 days”. Her abdomen does appear distended. You palpate all four of her abdominal quadrants and note they are soft and appear to be non-tender. You auscultate for bowel sounds and note that they are active in all quadrants. You ask Linda if she is passing gas, “you betcha” she replies. She tells you that before coming to the hospital she was 135lbs and that she believes she has lost weight. You ask her why she thinks this, “I haven’t eaten well since arriving to this hospital. I have no appetite and it seems to take a lot of effort to eat”. She seems to be moving her legs in bed frequently while you are interviewing her. You ask Linda, “Do you have pain in your legs?”. Linda explains that she does not have pain but rather wants to keep moving them so that she doesn’t “stiffen up”. Linda goes on to explain that she has had soreness and morning stiffness every morning for the last several years and her family doctor is investigating for arthritis. She denies requiring any mobility aids currently and denies any history of falls. You notice that Linda has a foley catheter insitu. There is 400cc of straw colour urine in the foley collection bag. You ask her why she has a catheter in. Linda states “the nurses put this catheter in while I was in the emergency department, they needed a urine specimen. Truthfully, I would like it out so that I can try to pee on my own”. Before terminating the interview, you hand Linda her cosmetic bag that she requested. She tears up and states, “I am not feeling much like putting make-up on. I fear that I will never get better. I seem to be wasting away in this bed. I am on my own with two kids in university so all that I can think about is who is going to work to pay for what they need. I need to get out of here!”. LAB VALUES AND DIAGNOSTIC TESTS FOR CASE STUDY #2 You can use the values below to add to the case study provided. If you have already developed the case study using your own lab values that is also acceptable. The idea is to explore the data and learn how to collect it in a comprehensive format along with identifying the priority nursing problem. WBC-16.2 Hgb-123 Plt-361 Na+-134 k-3.3 Cr-69 Glucose-6.2 CXR shows consolidation to left lower lung.

Medical Diagnosis (overview of disease and cause): ( Clinical Manifestations (signs and symptoms):

(2) Associated lab values and diagnostic tests including normal values:

(3) Medical/Surgical interventions prescribed by the physician: (2)

Nursing assessments needed (physical, psychological, social, spiritual, economic): (2)

Common nursing diagnosis (NANDA): (1)

Nursing interventions for holistic care (include client/family teaching): (3)

Answer 1

Medical Diagnosis (overview of disease and cause): ( Clinical Manifestations (signs and symptoms):

answer:

The patient has presented to the emergency department with complaints of shortness of breath. She has had a productive cough for 3 days with a fever. She is admitted to the hospital with pneumonia and septicemia.

Medical Diagnosis is Left lower lung. pneumonia and septicemia with hypercholesterolemia and hypertension and arthritis(under investigation ) with 2 days history of constipation probably .caused by depressed immunity due to iron deficiency and stress as its underlying cause.

The patient has an iron deficiency for which she is undergoing treatment .She is also severely stressed in her personal life as she has the only earning member and has the responsibility to earn for the two kids which causes her stress.She also has hypercholesterolemia and hypertension.All these can cause depressed immunity and these could be the reasons responsible for the pneumonia.

The nursing priority here is to maintain a clear airway by helping patient clear the cough,facilitate effective breathing by teaching patient deep breathing /chest splinting for pain and provide adequate hydration for good circulation and blood pressure maintenance

( Clinical Manifestations (signs and symptoms):

Answer:

The patient is admitted to the hospital with pneumonia and septicemia.The patient's clinical signs and symptoms include

  1.Increasing shortness of breath with fever and cough with productive sputum.

2.Tachypnea with respiratory rate is 24/min with evidence of accessory muscle use (abdominal breathing).

3.Auscultation of the  chest reveals  decreased breath sounds in the Left Lower Lung.

4.Hypoxaemia with oxygen saturation to be 92% on 2L of oxygen via nasal prongs.

5. Pleuritic chest pain improving on posture. as clinically manifested by heaviness in chest with pain on coughing with pain score of 7/10,.After moving up in bed it  is 2/10.

(2) Associated lab values and diagnostic tests including normal values:

Answer:

The associated lab values and diagnostic tests including normal values are discussed below.

a]leucocytosis with elevated WBC count indicates sepsis.

The normal WBC count  in the blood day is 4.5 to 11* 10⁹per liter .The patients value here is 16.6 which indicates elevation of the WBC count and points to leucocytosis due to the systemic sepsis

WBC-16.2 elevated normal levels are (4.5 to 11)* 10⁹ per liter ---leucocytosis

Hgb-123 ---normal ranges[normal 120-152 grams/liter]

Plt-361---normal ranges(140-400 thousand/microlitre]

Na+-134---normal ranges{135-145meq/l]

k-3.3 ---slight hypokalemia [normal ranges is 3.5 to 5.2 mmol/l]

Cr-69 --normal [normal 53 to 115 micromoles/l]

Glucose-6.2---normal 3.9-5.4 normal fasting levels [ random<7.8mmol/l is normal]

c] CXR shows consolidation to left lower lung.

Normal CXR--hyperlucent lung fields,no consolidation.

d]oxygen saturation to be 92% on 2L of oxygen via nasal prongs. [normal oxygenation 95-100%.on room air]

(3) Medical/Surgical interventions prescribed by the physician: (2)

Answer:

The medical interventions prescribed by the physician as per the case study are

1.intravenous antibiotic administration :The patient has been on IV ceftriaxone 1gm q24hrly

2 .administration of ramipril 10mg daily, atorvastatin 20 mg daily and iron replacement daily to treat hypercholesterolemia and hypertension and iron deficiency anemia.

3.administration of oxygen by nasal prongs :2L of oxygen via nasal prongs.

4.foley's catheterization:The nurses put the catheter in while the patient  was in the emergency department as they needed a urine specimen.

5.Regular monitoring of the patient by pulse oximetry ,laboratory investigations, x-ray chest and input output monitoring.

6..Assessment by the physician for the patients arthritis

Nursing assessments needed (physical, psychological, social, spiritual, economic): (2)

Answer:

The relevant nursing assessments needed (physical, psychological, social, spiritual, economic) for this patient are discussed below.

1.Physical assessment of the patient with the taking of the vital signs at regular intervals in order to monitor the patient's temperature,pulse and blood pressure closely. Monitoring of the patient's oxygenation by regular pulse oximetry,,ABG if available.Observation of the skin and the mucous membranes to observe for cyanosis and dehydration.General systemic examination with the specific emphasis on the examination of the respiratory system to hear the breath sounds,presence of foreign sounds ,crackles,. Monitoring of the respiratory rate and the effective coughing efforts to rule for worsening tachypnea/respiratory failure mandating mechanical ventilation.

2.Psychological assessment of the patients mind make up as the patient is crying and displaying signs of anxiety and ineffective coping. During the conversation the patient expresses fear that she will never get better. ,she seem to be wasting away in this bed.The nurse must perform a psychological assessment and a rule out the concomitant presence of depression or anxiety disorder in the patient and provide therapeutic counseling of the patient with calm patient hearing and empathetic approach.

3.Social assessment: Assessment of the family support system of the patient as the patient is highly anxious about the responsibility she carries even though she is very sick.She is also concerned about the financial needs about the two kids who are in university as she is the only one to earn and provide for the kids.Attempt should be made by the nursing staff to understand the the social support system of the patient and obtain family support for the sick patient if possible by talking to the patient about the same.

4.Assessment of the socio-economic background: The patient seems to be in a economic crisis as she is the only one earning the and her being sick makes it difficult for the payment of fees of her two kids at University and this leads to severe anxiety in the patient.The socio economic background of the patient must be assessed and  kept in mind while giving the counseling and attempts made to provide economic help to the patient as per the provisions of the hospital

Common nursing diagnosis (NANDA): (1)

Answer:

The common Nanda diagnosis for this condition is impaired gas exchange related to inflammation of the the airways and the alveoli secondary to pneumonia as evidenced by shortness of breathless,evidence of accessory muscle use (abdominal breathing).,cough with productive sputum, tachycardia, increase in the respiratory rate and low oxygen saturation 92%on pulse oximetry and lung consolidation seen on X-ray.

The other common nursing diagnosis for this condition is ineffective Airway clearance related to airway inflammation,sputum production,pleuritic chest pain secondary to pneumonia as evidenced by the increase in the respiratory rate, use of accessory muscles of respiration ,shortness of breath, presence of cough with sputum production,hypoxemia with 92% oxygen saturation on pulse oximetry and lung consolidation on the x-ray film.

Nursing interventions for holistic care (include client/family teaching): (3)

answer:

The nursing interventions for holistic care in this patient include the following.

1.The therapeutic medical nursing interventions include the maintenance of oxygenation, monitoring the input-output ,providing adequate hydration, assisting the patient with proper breathing techniques and helping with effective coughing in upright position by splinting of the chest for the chest pain, assisting the patient with respiratory physiotherapy so as to bring out this cough and administering medications as ordered by the physician.

2.The therapeutic nursing psychological intervention includes patient counseling in order to help the patient alleviate the anxiety and psychological distress by speaking to the patient , understanding the reasons for her anxiety providing empathy.and explaining to her about the course of the disease so as to give the patient the realistic ideas about her recovery and the allay/decrease the fears of wasting/ permanent hospitalization.

3.The nursing teaching intervention for the patient education includes educating the patient to try to get adequate rest by providing for privacy and undisturbed atmosphere to rest. The patient should be educated to take deep breaths and try to cough out as much as sputum as possible in the cough.The patient should be taught about the importance of positioning in preventing the pain while coughing and importance of mobility and ambulation. The patient should also be educated about the importance of taking lots of water and clear fluids in order to loosen the mucus.The patient should be educated about the general hygiene measures like washing hands with soap and water and coughing or sneezing into tissue with use of sanitizer/ hand rubs for preventing infection