Please enable JavaScript.

Coggle requires JavaScript to display documents.

Our patient is a 73 yr. old Female :<3:, The chaplain of the hospice or…

- - - - Patient is diagnosed with pneumonia
        
        Nursing Diagnosis #3 :star:
        
        Risk for spread of infection related to inadequate primary defenses- decreased (bronchial) ciliary action, and stasis of body fluids.
        
        Goal :recycle:
        
        Patient will achieve timely resolution of current infection without complications by 1500 on 2-8-2021. (Doenges, Moorhouse, Murr, 2019)
        
        Patient is free from emerging symptoms suggestive of a secondary infection and complications of pneumonia by 1500. Patient is afebrile, WBC count is within normal limits, and patient denies new symptoms. Patient’s blood pressure is normal relative to baseline, suggesting absence of septic shock. Patient’s respiration rate is within normal limits. Patient’s heart rate is within normal limits. Patient is free of pain currently. Vitals suggest absence of complications from pneumonia.
        
        8 more items...
        
        Administer antimicrobials, as indicated, such as penicillin combinations (piperacillin-tazobactam). Rationale: These drugs are used to combat most of the microbial pneumonias. (Doenges, Moorhouse, Murr, 2019)
        
        Patient prescribed Piperacillin-Tazobactam 3.375 g in NS extended infusion
        
        IV Site
        
        1 more item...
        
        Adverse Effects :warning:
        
        1 more item...
        
        Piperacillin: Binds to bacterial cell wall membrane, causing cell death.
        Tazobactam: inhibits beta lactamase, an enzyme that can destroy penicillins. (Nursing Drug Handbook, 2019)
        
        Intervention #2 :check:
        
        Instruct patient concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, and odor of secretions. Rationale: Although patient may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum reflect resolution of pneumonia or development of secondary infection. (Doenges, Moorhouse, Murr, 2019)
        
        Encouraged expectorations :check:
        
        1 more item...
        
        Intervention #3 :check:
        
        Investigate sudden changes or deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, and changes in sputum characteristics. Rationale: Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any organ system include lung abscess, empyema, bacteremia, pericarditis, endocarditis, meningitis, encephalitis, and superinfections. (Doenges, Moorhouse, Murr, 2019)
        
        Labs :pen:
        
        2-8-2021 RBC 3.31 Low
        
        This value is trending
        upwards from 3.28 on 2-6-2021.
      - Patient is placed on FALL precautions, ASPIRATION precautions, HOB @ 30º to prevent hypotension
        
        NPO, continuous TPN infusion
        
        TPN order :pencil2:
        
        Adult peripheral TPN continuous infusion 1,920 mL per 24 hours, IV
        
        Anterior left forearm 20 g placed on 2-5-2021 for TPN
        
        TPN @ 80 mL/hour
        
        Site is clean, dry, and intact, free from erythema and edema
        
        TPN Implications
        
        Blood glucose is important to monitor during TPN administration to ensure hyperglycemia is not triggered. (Phillips, 2018)
        
        1 more item...
        
        Intravenous parenteral nutrition must be administered through a dedicated infusion port and filtered with a 0.22-micron inline filter. Discard any unused portion after 24 hours hang time. (from pt.’s MAR)
        
        Order :pencil2:
        
        20% Fat emulsion co-administered with TPN, 100 mL per 24-hour period, IVPB, @ 80 mL/hour
        
        2 more items...
        
        Since the patient could not swallow, is NPO, is underweight (40.5 kg for 5'4" frame), and at risk for malnutrition, a decision was made by the care team to temporarily run TPN peripherally before peg tube placement. This is not the industry standard of care, however. According to Medical Surgical Nursing, "When the patient requires intensive nutrition support, the HCP provides centrally administered TPN. TPN is delivered through access to central veins, usually through a PICC line or the subclavian or internal jugular veins." (Heimgartner, N., Ignatavicius,
        D., Workman, L., & Rebar, 2018)
        
        Daily Weight Assessment :check:
        
        1 more item...
        
        Labs :pen:
        
        1 more item...
        
        TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth. (Phillips, 2018)
        
        Order for procedure :pencil2:
        
        Peg tube placement scheduled for 2-8-2021
        
        Pt. Request :check:
        
        Patient requests mouth swab due to dryness related to NPO status
        
        Intervention :check:
        
        Swabbed oral cavity with peroxide solution seven times upon request throughout shift. Mucous membranes replenished with moisture upon assessment. Applied Chapstick to prevent dry lips.
        
        Activity orders :pencil2:
        
        Up with assistance, bedside commode, bedrest, HOB flat for hypotension, ambulate pt. every shift
        
        Integumentary Evaluation :check: Risk of impaired skin integrity related to bedrest
        
        PT order :pencil2:
        
        5 days a week for 30 minutes each session
        
        Morse Fall Risk Assessment
        
        Score of 45, High Fall Risk
        
        Bed in lowest position with 2 side rails up to prevent falls. Patient wearing beige nonskid socks bilaterally with yellow fall-risk armband applied. Sign on patient’s door indicates risk for falls. Fall precaution posters present on walls of room within patient’s line of sight. Call bell left within patient's reach throughout shift.
        
        Patient is free from falls throughout shift
      - Skin turgor on medial chest <3 seconds, urine output is 270 mL of amber colored urine in 8 hours, suggesting pt. has adequate fluid status currently
        
        2-8-2021 BUN is 23
        
        Evaluation :checkered_flag:
        
        This value suggests
        patient’s fluid balance is returning to normal after dehydration upon admission
      - Psychosocial :<3:
        
        Provided emotional support by actively listening to patient throughout shift. Notified patient of existence of clergy at hospital. Conveyed acceptance to patient during conversation.
        
        Palliative Care :silhouettes:
        
        Patient participated in end-of-life care discussion with palliative care team on 2-6-2021.
        
        Spiritual support is typically the work of hospital chaplains, who work with local religious and spiritual leaders to help provide spiritual support for patients near the end of their lives. The goal is to help the person feel peace and comfort. (Spiritual support: End-of-life care 2018)
        
        Spiritual Support :silhouettes:
        
        Spiritual support, part of hospice and palliative care, may help people cope better with the hard, spiritual questions that come up at the end of life. Spiritual support is not the same for everyone. To be most effective, it should match a person’s beliefs. (Spiritual support: End-of-life care 2018)
        
        Diagnosis of serious illness may cause someone a loss of faith or hope. (Spiritual support: End-of-life care 2018) Spiritual distress can lead to other conditions, including:
        
        Sequelae of spiritual distress :red_flag:
        
        1 more item...
        
        Sense of isolation
        
        Loss of inner peace
        
        A hard time dealing with illness symptoms
        
        Alcohol or drug abuse
        
        Spiritual Support :silhouettes:
        
        Spiritual support is a low- to no-risk treatment option for patients who have trouble with spiritual distress near the end of life. Spiritual support should be given with careful thought to the patient. The wrong kind of spiritual support could do more damage than good. A spiritual assessment can help a chaplain or other spiritual support professional make the right choices for the patient.(Spiritual support: End-of-life care 2018)
        
        1 more item...
    - - Labs :pen:
        
        2-1-2021 D-Dimer 2.50, High
        
        Medication :check:
        
        Patient prescribed heparin injections every
        12 hours of 5,000 units, subcutaneously
        
        2-8-2021 APTT 72 seconds
        
        Implication :warning:
        
        1 more item...
        
        Bleeding, heparin induced thrombocytopenia, anemia, osteoporosis, fever. Assess for signs of bleeding and hemorrhage, nosebleed, unusual bruising, black or tarry stools, a fall in hematocrit or BP. (Nursing Drug Handbook, 2019)
        
        Pt. Response :<3:
        
        1 more item...
        
        Lab Evaluation :checkered_flag:
        
        1 more item...
        
        Mechanism of Action :explode:
        
        Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. In low doses, prevents the conversion of prothrombin to thrombin by its effects on factor Xa. Higher doses neutralize thrombin, preventing the conversion of fibrinogen to fibrin. (Nursing Drug Handbook, 2019)
      - Cardiac Assessment :check:
        
        S1 and S2 noted, possible S3 present
        
        Assessment :check:
        
        Patient connected to telemetry, normal sinus rhythm identified
      - Labs :pen:
        
        2-8-2021 Hemoglobin 10.2 Low
        
        Observe patient for signs and symptoms of
        anemia (dizziness, tachycardia, weakness, dyspnea at rest). (Key, 2018)
        
        Patient is generally weak but denies dizziness. Patient is free from tachycardia throughout shift. Patient is free from SOB during transfer from bed to chair and while ambulating with assistance to bedside commode utilizing gait belt. Patient is free from syncope throughout shift.
        
        This value is trending
        upwards from 10.1 on 2-6-2021.
    - - Patient is prescribed Pantoprazole injection 40 mg IV daily, dilute in 10 mL NS. to prevent stress ulcers.
        
        Clostridium difficile associated diarrhea, abdominal pain, hyperglycemia, bone fracture. (Nursing Drug Handbook, 2019)
        
        Patient is free from diarrhea, abdominal pain, hyperglycemia, and bone fractures during shift
        
        Assessment :check:
        
        Patient states last BM was "yesterday", of small amount and of normal consistency, no loose stool reported
        
        Mechanism of Action :explode:
        
        Pantoprazole binds to an enzyme in the presence of acidic gastric pH., preventing the final transport of hydrogen ions into the gastric lumen. (Nursing Drug Handbook, 2019)
  - - - 14 French NG tube placed in right nostril on 2-7-2021 at a depth of 45 cm. to decompress gastric contents. Tube connected to low intermittent suction
        
        XRAY :warning:
        
        XRAY performed @ 0614 on 2-8-2021 to check NG tube placement
        
        Impression :pen:
        
        Gastric decompression tube tip overlying the GE junction, proximal side hole in the distal esophagus. Recommend advancing.
        
        Advanced NG tube from 45 cm. to 55 cm. on 2-8-2021, at a rate of 1 cm/second
        
        3 more items...
    - - Binder is clean, well fitting, incision is well approximated, skin bunching present along perimeter of transparent dressing, incision is free of erythema, edema, and purulent drainage on 2-8-2021
        
        Patient Education :silhouettes:
        
        Taught patient to splint incision during coughing, ambulating, and turning to reduce pain and prevent dehiscence. Patient acknowledged teaching and verbalized understanding. Observed patient splinting during coughing after education.
- - - - Patient has COPD
        
        Patient displays congestive cough throughout shift, with copious mucus secretions. Combined with pneumonia, pt. is at increased risk for aspiration
        
        Intervention :check:
        
        Provided basin to pt. to emit clear, thick secretions, (2-3 each hour of shift), amounting to around 3-5 mL each expectoration
        
        Patient maintained clear airway and was free from aspiration throughout shift
        
        Offered incentive spirometry session, patient declined 2 invitations. Patient states she is “tired.” Educated patient about importance of incentive spirometry and mechanism of action. Patient verbalized understanding of teaching.
        
        Intervention :check:
        
        Patient accepted 3rd invitation for incentive spirometry and achieved a peak inspiration of 500 mL, with a goal of 1,000 mL in place.
        
        Ineffective airway clearance related to exudate in alveoli as evidenced by copious mucus secretions on 2-8-2021.
        
        Patient will display patent airway with breath sounds clearing and absence of dyspnea and cyanosis by 1400 on 2-8-2021. (Doenges, Moorhouse, Murr, 2019)
        
        Patient met goal of absence of cyanosis by 1400. Clearing breath sounds and dyspnea will need continued efforts to improve. Continuation of incentive spirometry will be helpful to mobilize secretions and clear airway effectively. Patient will need to be monitored closely to prevent aspiration from secretions.
        
        Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes. Rationale: Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction. (Doenges, Moorhouse, Murr, 2019)
        
        Auscultated pt.'s respirations. Patient’s breath sounds are hyper-resonant bilaterally, anteriorly, posteriorly, and laterally.
        
        Assessment :check:
        
        Patient free from crackles, wheezes, and rhonchi upon auscultation.
        
        Intervention #1 :check:
        
        Assess rate and depth of respirations and chest movement. Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. (Doenges, Moorhouse, Murr, 2019)
        
        Assessment :check:
        
        1 more item...
        
        Intervention #3 :check:
        
        Assist patient with frequent deep-breathing exercises. Demonstrate and help patient, as needed, learn to perform activity, such as effective coughing while in upright position. Rationale: Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-clearing mechanism, assisting the cilia to maintain patent airways. An upright airway favors deeper, more forceful cough effort. Note: Cough associated with pneumonias may last days, weeks, or even months. (Doenges, Moorhouse, Murr, 2019)
        
        Incentive Spirometry :checkered_flag:
        
        1 more item...
        
        O2 Status :warning:
        
        Patient is breathing room air
        
        Auscultated pt.'s respirations. Patient’s breath sounds are hyper-resonant bilaterally, anteriorly, posteriorly, and laterally.
- - - - Families are an essential component of care, health and wellbeing; quality and safety initiatives recognize the role they play in ensuring high standards of care, and they are allies for quality and safety within the healthcare system. (Brent, Santy-Tomlinson, & Hertz, 2018)
        
        Family :silhouettes:
        
        Families are an essential part of the patient care continuum and a fundamental characteristic of holistic care is that nurses must collaborate with others to achieve best practice. (Brent, Santy-Tomlinson, & Hertz, 2018)
- - - - Support Group :silhouettes: