Question

VCE Activity# 1:

PN105C

Head, neck and chest assessment:

Graded:

Go to VCE in your Module, and click on virtual clinical Excursion

click on online virtual hospital

Enter medical surgical unit, Period of care 1,

Patient Name: Patricia Newman in Room # 406

Read the report.

Change of Shift (1901-0730) Report ---------------

Patient admitted to Medical Unit at 0300 from Emergency Department. On oxygen therapy of 2 liter flow by nasal cannula with SpO2 of 89%. Intravenous fluids of D 5 ½ NS with 20 mEq KCl at 75 ml/hr infusing in right forearm. IV site clear without redness or edema. Labored and shallow respiratory effort with use of some accessory muscles. Bilateral breath sounds coarse. Tachypneic. Productive cough of thick yellow sputum. Sputum gram stain, culture and sensitivity pending. Chest x-ray results reveal generalized hyperinflation and right middle and lower lobe infiltrates. Tachycardic. Patient sleeping intermittently. 0500 lab tests drawn. ABG: ph 7.33, PaO2 70, PaCO2 47, HCO3 26, SpO2 92%. 0715 vital signs: T 102F, BP 168/94, P 112, RR 32, SpO2 85% in room air. Patient removed nasal cannula.

Check patient’s chart/ Kardex and look for this patients Medical diagnosis.

Medical diagnosis : Pneumonia

Enter Patricia Newman’s room

406

Identify patient (check armband)

MRN: 1868097 Room: 406

Patient: Patricia Newman

Sex: Female Age: 61

Physician: Joseph Molina, M.D.

Check allergies

Allergies: NKA

Read initial observation

Patricia sitting up in bed with call light within reach. Alert and oriented. Labored and shallow respiratory effort. Nasal cannula off. SpO2 85%. IV infusing at 75 ml/hr via infusion pump.

Click on vital signs: note patients vital signs? Do you see any abnormal values? Take a note.

BP: 166/92 SP02: :88 T°F: 102.3 HR: 115 RR: 34 Pain: 0

Click on clinical alert? Note any alerts.

Clinical Alert at 0730

Elevated temperature of 102 F.

Now click on Patient care, you will see physical assessment with patient.

Head & Neck

Pupils bilaterally equal and reactive to light.

Ears without swelling or discharge, small amount cerumen in ear canal.

Nares clear without redness, swelling, or discharge.

Neck: Skin warm, dry, and intact. No rashes or lesions.

Back & Spine : Skin warm, dry, and intact. No rashes or lesions.

Upper Extremeties : Skin warm, dry, and intact.

No rashes or lesions. Pressure points free of redness or irritation. Peripheral intravenous site clear and without redness or edema.

Abdomen : Skin warm, dry, and intact. No rashes or lesions.

Abdomen soft, flat, and nondistended.

Pelvic : Skin warm, dry, and intact. No rashes or lesions.

Lower Extremeties : Skin warm, dry, and intact. No rashes or lesions.

Skin turgor adequate.

Perform following assessment on Patricia Newman by clicking:

HEAD AND NECK:

Click on following prompts:

Sensory :Pupils bilaterally equal and reactive to light.

Ears without swelling or discharge, small amount cerumen in ear canal.

Nares clear without redness, swelling, or discharge.

Neurologic : Cranial nerves intact without apparent deficits.

Lymphatic: Enlarged superficial cervical node.

No palpable tenderness or masses.

Thyroid : No palpable tenderness or masses.

Musculoskeletal :Symmetrical skull and face. Full range of motion.

No apparent deficits in sensation or movement.

Integumentary : Skin warm, dry, and intact.

No rashes or lesions. Skin turgor adequate.

Hair dry and brittle.

Gastrointestinal : Dentition intact. Oral mucosa dark pink and moist without lesions.

Gums with some redness and swelling.

Mental Status : Alert and oriented to person, place, time, and situation.

Speech, perceptual ability, and cognition age appropriate.

Mild anxiety level with labored respiratory effort.

CHEST:

Integumentary : Skin warm, dry, and intact.No rashes or lesions.

Respiratory : Labored and shallow respiratory effort.

Patient removes nasal cannula for assessment against RN advice.

Bilateral breath sounds with coarse crackles auscultated throughout lung fields.

Aeration mildly decreased.

Productive cough of thick yellow sputum.

Employing some accessory muscles.

Tachypnea .

Exertional dyspnea.

Oxygen saturation of 90% in 2 liter flow oxygen via nasal cannula.

Cardiovascular : Apical rate and rhythm regular and even.

Sinus tachycardia.

S1 and S2 auscultated.

No murmurs, clicks, or rubs.

No jugular vein distention.

Musculoskeletal : Chest contour symmetrical.

Impaired chest expansion with shallow and labored respiratory effort.

Breasts :No palpable tenderness or masses.

No abnormalities noted.

BACK AND SPINE:

Integumentary : Skin warm, dry, and intact.

No rashes or lesions.

Respiratory : Bilateral breath sounds with coarse crackles throughout lung fields.

Hyperresonance to percussion.

Musculoskeletal : Spinal curvature straight and without deformities.

Full range of motion without apparent deficits in sensation or movement.

Document any abnormal findings from the above assessment:

Go to nurse client interaction at 7:30 am and watch the video.

Based on the above assessment and patient interaction, identify at least 2 problems Patricia Newman is having?

Write down 4 to 5 nursing interventions you will do to resolve those problems?

Answer 1

Bases on the finindings on assessement we can understand that patint had severe respiratory problem tachypnoea and dyspnoea on exertion ,and also had tachy cardia.Lung examnination reveals that she had productive sputum followed by an infection.hense the nursing diagnosis focus on respiratory status and infection.

1 - Ineffective breathing pattern tachypnoea related to disease condition.

It is characterised by changes in respiratory rate and depth,cough,dyspnoea,increased work of breathing ,use of accessary muscles,Tachypnoea,use of accessary muscles.

Interventions	Rationals
Assess and record respiratory rate and depth frequently	It is important to take an action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.
Place patient with proper body alignment for maximum breathing pattern,preferably in fowlers position.	A sittingbposition permits maximum lung excursion and chest expansion.
Encourage diaphragmatic breathing for patients with chronic disease.	This method relaxes muscle and increases the patients oxygen level.
Provide respiratory medications and oxygen as per doctors order.	Beta adregenic agonist medications relax airway smooth muscle and cause bronchodilation to open air passages.
Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing.	To facilitate adequate clearance of secretions.
Encourage patient or significant other proper breathing ,coughing,and splinting excersise	These allow sufficient mobilization of secretions.
Refer the patient for evaluation of excersie potential and development of individulized excersise programe.	Excersise promotes conditioning of respiratory muscles and patients sense of well being.

Outcome -There are some expected outcomes for the interventions.

• Patient maintains an effective breathing pattern as evidanced by relaxed breathing at normal rate depth and absence of dyspnoea.
• Patients respiratory rate remains within established rates.
• Patient reports feeling rested each day.
• Patient demonstrats maximum lung expansion with adequate ventilation.
• Patient acrries out ADLs breathing pattern remains normal.

2-Impaired gas exchange related to excessive or thick secretions ,followed by infection.

Main symptoms here are Dyspnoea,Tachycardia,Abnormal breathing.

INTERVENTION	RATIONALES
Assess the respiratory rate and pattern	Incressed respiratory rate ,use of accessary muscles ,may seen with hypoxia
Position the patient with head elevated in a semi fowlers position	Upright position allows incresed thoracic capacity.full dedcent of diaphragm
turn the patient every two hours .	Turning is important to prevent complications of immobility
Encourage or assist with ambulation as per physicians order	Ambulation facilitaes lung expansion,secretion clerance.
Administer humidified oxygen throug appopriate devise	A patient with chronic lung disease may need a hypoxia drive to breath and may hypoventilate during oxygen therapy.
Suction neccessary	Suction clears secretions if the patient is not capable of effectievly clearing the airway.
Administer medications as prescribed.	The type depends on the infection,bronchodilators.