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54-year-old female: Admitted for acute hypoxemic respiratory failure…
54-year-old female:
Admitted for acute hypoxemic respiratory failure secondary to pneumonia
Priority altered nursing concepts:
Health & illness concepts:
Perfusion
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Priority nursing care problems (nursing diagnosis): Altered perfusion related to reduced coronary blood flow as evidenced by abnormal cardiac cath & echo results.
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Client-focused outcomes (SMART goal): The patient will remain hemodynamically stable post-PCI for the duration of acute care hospitalization.
Nursing interventions (Lewis, 2017):
Monitor ECG for dysrhythmias or other changes
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Monitor patient for chest pain and other sources of pain or discomfort
Monitor IV infusions of anticoagulants, antiplatelets
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Perform assessment and compare to baseline
Vital signs
Pulse oximetry
Heart & breath sounds
Neurovascular assessment of extremities used for procedure
Assess for hematoma
Assess for bleeding
Fluid & electrolyte balance
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Priority nursing care problems (nursing diagnosis): Fluid and electrolyte imbalance related to impaired kidney function as evidenced by abnormal lab values.
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Client-focused outcomes (SMART goal): The patient will maintain stable fluid and electrolyte levels for the duration of acute care hospitalization.
Nursing interventions (Lewis, 2017).
Monitor labs and assess patient for signs and symptoms of electrolyte imbalances
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Administer electrolyte replacement as ordered
Monitor response to electrolyte replacements, including repeat lab results as appropriate
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Fluid restriction as ordered
Instruct patient on fluid and nutrition restrictions as appropriate
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Limit foods that are high in dietary potassium (Kuchta, VanBuskirk, & Houglum, 2007)
Avoid foods that contain potassium chloride (Kuchta, VanBuskirk, & Houglum, 2007)
Check ingredient lists and avoid foods that contain phosphorus (Kuchta, VanBuskirk, & Houglum, 2007)
Hemodialysis on Tuesdays, Thursdays, & Saturdays
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Educate patient about hemodialysis (Kuchta, VanBuskirk, & Houglum, 2007)
Elimination
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Attribute concept:
Functional ability
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Professional nursing concept:
Patient education
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Medical diagnoses:
Cardiac:
Coronary artery disease
Ischemic cardiomyopathy
Unstable angina
Congestive heart failure
Essential hypertension
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Renal:
End stage renal disease (on dialysis)
Anemia due to end stage renal disease
Diabetes mellitus 2
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Psychosocial:
Chronic anxiety & depression
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Non-compliance with medications
Infection:
Pneumonia
Abscess of right buttock
History of below the knee amputation (L)
History of amputation of toes (R)
Neurological:
Seizure disorder
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Reproductive:
Pelvic mass
Key medical diagnoses:
Acute hypoxemic respiratory failure
Pathophysiology
: In this case, excess secretions present in the patient's airways as a result of pneumonia resulted in a V/Q mismatch. This resulted in limited airflow (ventilation) but no change in blood flow (perfusion) for gas exchange, resulting in a V/Q mismatch (Lewis, 2017).
Etiology
: Hypoxemic respiratory failure is most commonly caused by
1) V/Q mismatch
, 2) shunt, 3) diffusion limitation, or 4) alveolar hypoventilation (Lewis, 2017).
Risk factors: (Lewis, 2017)
Respiratory disease
Cardiac disease
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CNS disease or injury
Chest wall (flail chest, pain, obesity)
Neuromuscular system (MS, Myasthenia gravis, ALS)
End stage renal disease (ESRD)
Etiology:
The leading causes of ESRD are diabetes and hypertension (Lewis, 2017).
Pathophysiology:
ESRD is a result of progressive, irreversible kidney damage. GFR is lost and the remaining nephrons hypertrophy to compensate. The end result is a systemic disease that involves all organs (Lewis, 2017).
Risk factors: (Lewis, 2017)
History of family renal disease
Diabetes
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Hypertension
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Repeat UTIs
Coronary artery disease (CAD)
Etiology
: The major cause of CAD is atherosclerosis. Atherosclerosis results from lipid deposits within the artery, causing endothelial injury and inflammation (Lewis, 2017).
Pathophysiology
: Atherosclerosis damages the endothelium of arteries. CAD develops over many years and consists of three stages: 1) fatty streak, 2) fibrous plaque, and 3) complicated lesion (Lewis, 2017).
Risk factors: (Lewis, 2017)
Non-modifiable:
Age
Gender
Ethnicity
Family history
Genetics
Modifiable:
Elevated serum lipids
Elevated BP
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Tobacco use
Physical inactivity
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Obesity
Diabetes
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Metabolic syndrome
Psychologic states
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Elevated homocysteine level
Pneumonia
Pathophysiology
: The offending organisms in the lungs trigger an exaggerated inflammatory response. The inflammatory response leads to fluid leaks from the capillaries into the alveoli (Lewis, 2017).
Etiology
: Pneumonia has many causes but is often related to impaired defense mechanisms. Organisms that cause pneumonia reach and infect the lungs in three ways: 1) aspiration, 2) inhalation, or 3) hematogenous spread (Lewis, 2017).
Risk factors: (Lewis, 2017)
Abdominal or thoracic surgery
Age > 65 yr
Altered consciousness: alcoholism, head injury,
seizures
, anesthesia, drug overdose, stroke
Bed rest and prolonged immobility
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Chronic diseases: chronic lung and liver disease, diabetes mellitus, heart disease, cancer, chronic kidney disease
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Immunosuppressive disease and/or therapy
Smoking
Tracheal intubation
Upper respiratory tract infection
Clinical nursing assessments:
Neuro:
Alert & oriented x4
Pupils equal & reactive
Pupils 2 mm bilaterally
Follows commands
Full sensation & motor strength in all extremeties
Richmond agitation sedation scale: 0 - alert & calm
Neuro medications:
Diabetic peripheral neuropathy
Gabapentin (Neurontin) capsule 200 mg - oral - nightly
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Seizure disorder
Levetiracetam (Keppra) tab 500 mg - oral - twice daily
Last seizure unknown
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Cardiac:
Normal sinus rhythm
Regular rate & rhythm
S1 & S2 present
No JVD
Bedside cardiac monitor on
Previously elevated BP now well-controlled with medications
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Capillary refill < 3 seconds in all extremeties
Right & left radial pulses +2
Right pedal pulse +1
No left pedal pulse - below the knee amputation
Right and left popliteal pulse +2
Cardiac medications:
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Hypertension:
Amlodipine (Norvasc) 10 mg - oral - daily
Carvedilol (Coreg) tab 25 mg - oral - twice daily with meals
Lisinopril (Prinivil, Zestril) tab 10 mg - oral - daily
Related to PCI:
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Clopidogrel (Plavix) tab 75 mg - oral - daily
Aspirin chewable tab 81 mg - oral - daily
CAD:
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Atorvastatin (Lipitor) 80 mg - oral - daily
Ezetimibe (Zetia) tab 10 mg - oral - daily (morning)
Angina:
Isosorbide mononitrate (Imdur) 24 hr tab 30 mg - oral - daily
No lipid profile found
GI:
Soft
Active in all 4 quadrants
Regular cardiac diet
No BM since admission
Tender on palpation related to large pelvic mass
GI medications:
Prophylaxis related to gastric stress ulcers
Lansoprazole (Prevacid) capsule 15 mg - oral - daily
GU:
Diminished urine production
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Hemodialysis on Tuesdays, Thursdays, & Saturdays: patient is compliant
GU medications:
End stage renal disease:
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Calcium acetate (Phoslo) capsule 1,334 mg - oral - three times daily with meals
Ferrous sulfate tab 325 mg - oral - daily with breakfast
B complex-vitamin C-folic acid (Dialyvite) 100-1 mg tab - 1 tab - oral - nightly
Pulmonary:
Dyspnea at rest
Rales noted in base of right lung
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Diminished breath sounds with crackles
Regular pattern & depth
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1 liter O2 via nasal canula
Pulmonary medications:
Pneumonia:
Piperacillin-tazobactam (Zocyn) 2,250 mg in NS 50 ml IVPB (116 ml/hr)
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Allergic rhinitis:
Loratidine (Claritin) tab 10 mg - oral - daily
Integumentary:
Generalized non-pitting edema
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Left forearm - AV fistula for dialysis (left arm restriction)
Right forearm IV (infusing)
Abscess to right buttock with wound vac
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Right foot - missing all toes
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Left leg - below the knee amputation
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Psychosocial:
Able to express feelings, needs, & thoughts
No family present
Lives in Eagle Butte (approximately 2 hours 45 minutes away)
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Does not follow up with appointments due to transportation issues
Non-compliant with medications
Psychosocial medications:
Chronic anxiety & depression:
Fluoxetine (Prozac) capsule 40 mg - oral - every morning
Closest hospital: USPHS Indian Health Service Hospital at Eagle Butte
Key diagnostic tests:
Cardiac:
Related to key medical diagnosis of CAD
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Cardiac cath completed March, 2019:
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Severe 3 vessel disease
Not eligible for CABG due to patient comorbidities
70% mid LAD stenosis
70% mid circumflex stenosis
80-85% mid RCA stenosis
Echo completed March, 2019:
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Mild LV enlargement
Mild to moderate concentric LV hypertrophy
LV systolic dysfunction 45%
Hypokinesis of the inferior posterior wall
EKG completed 10/1/2019 (normal)
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Echo completed 9/25/2019:
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Ejection fraction 45%
L ventricular systolic dysfunction
Grade 2 L ventricular diastolic abnormality
Cardiac cath with PCI completed 9/30/19:
With Impella assist (L femoral site)
PCI of the proximal/mid RCA with rotational artherectomy: 2 drug-eluting stents placed
PCI of the proximal/mid LAD: 2 drug-eluting stents placed
PCI of the proximal/mid circumflex: 2 drug-eluting stents placed
Abnormal labs related to cardiac function:
Chem profile:
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Potassium: 5.1 - on the higher side (normal 3.5-5.1)
Albumin: 3.4 - low
Sodium: 130 - low (normal 135-145)
Cardiac profile:
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LD: 288 (high)
Troponin 1: < 0.030 (high)
BNP: > 4,500 (high)
No lipid profile found
Renal:
Related to key medical diagnosis of ESRD
Abnormal labs related to renal function
Chem profile:
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Sodium: 130 - low (normal 135-145)
Chloride: 95 - low (normal 98-107)
Anion gap: 14 - high (normal 3-11)
BUN: 45 - high (normal 7-25)
Creatinine: 6.73 - high (normal 0.60-1.20)
eGFR: 6 - low (normal > 60)
Glucose: 122 - high (normal 70-105)
Calcium: 8.4 - low (normal 8.6-10.3)
Albumin: 3.4 - low
CBC:
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RBC: 2.25 - low (normal 3.70-5.30)
Hemoglobin: 7.2 - low (normal 11.5-15.5)
Hematocrit: 21.2 - low (normal 34-45%)
RDW: 15.4 - high (normal 11.5-14%)
Iron/anemia profile:
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Iron: 10 - low (normal 50-175)
Ferritin: 791.8 - high (normal 11-307)
Iron saturation: 7 - low (normal 13-50%)
TIBC: 138 - low (normal 250-450)
UIBC: 128 - low (normal 155-355)
Urinalysis:
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Glucose, urine: 150 - abnormal (normal - negative)
Protein, urine: > 500 - abnormal (normal - negative)
Leukocytes: trace - abnormal (normal - negative)
pH, urine: 9.0 - high (normal 5.0-8.0)
WBC, urine: 10-14 - abnormal (normal 0-4)
POC glucose:
146 - high
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Respiratory:
Related to key medical diagnoses of acute hypoxemic respiratory failure & pneumonia
Chest x-ray completed 9/27/19:
Cardiomegaly
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Diffuse pulmonary infiltrates
CT of abdomen/pelvis:
Dense consolidation in the right lung base - suggestive of pneumonia
Multifocal bilateral opacities - suggestive of infection
Small pericardial effusion
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Large central calcified pelvic mass (13-14 cm)
Abnormal labs related to pneumonia:
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CBC:
WBC: 10.9 - high (normal 4.5-10.5)
Other chem:
Procalcitonin: 8.94 - high (normal 0.10-0.49)
